Prior Authorization

Prior Authorization

Iowa Total Care uses prior authorizations to ensure that all care delivered to our members is medically necessary and appropriate based on the member’s type and severity of condition. We work with our contracted providers to review certain testing and treatment decisions and verify that they are consistent with our clinical policies and philosophy of care.

Some services require prior authorization from Iowa Total Care in order for reimbursement to be paid to the provider. Check to see if a prior authorization is necessary by using our online tool. Prior authorization must be obtained prior to the delivery of certain elective and scheduled services. Family planning, emergency room, post-stabilization services, and table top x-rays never require prior authorization.

Prior authorization requests may be submitted by fax, phone or the Secure Provider Web Portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified. Iowa Total Care will process most standard prior authorization requests within five days. If we need additional clinical information or the request needs to be reviewed by a Medical Director, additional days may be needed to make a determination. Detailed information on prior authorization determination timelines is included in the Provider Manual.

Please Note: Iowa Total Care has partnered with the National Imaging Associates (NIA) for the management of non-emergent, high-tech, outpatient radiology services through prior authorization. Under this program prior authorizations must be obtained through NIA. For more information about this program, see the NIA Provider Resources page.

Iowa Total Care’s Medical Management department hours of operation are Monday through Friday, 8 a.m. to 5 p.m. CST (excluding holidays). After normal business hours, we have an after hours service available to answer questions and intake requests for prior authorization. Failure to obtain the required prior authorization for a service may result in denied claims. All services are subject to benefit coverage, limitations, and exclusions, as described in applicable plan coverage guidelines. All out-of-network services require prior authorization except for family planning, emergency room, post-stabilization services and table top x-rays.

Iowa Total Care providers are contractually prohibited from holding any member financially liable for any service administratively denied by Iowa Total Care for the failure of the provider to obtain timely prior authorization.