Prior Authorization/Referral

Some covered services or prescription drugs may need approval from Iowa Total Care, and this is called a Prior Authorization (PA). You do not need a paper referral from Iowa Total Care to see a doctor. But, your doctor may need to request approval from Iowa Total Care before you receive the service.

You can check to see if your service was approved by logging into your Member Portal.

Some Medicaid members have a copay for some brand name prescription drugs. You can find more information on copays on the Pharmacy Benefits page.

Below is a list of services that may require approval. Most services require approval if performed by a doctor who is not in the Iowa Total Care network (also known as an out-of-network provider). There are services that require approval even if the doctor is part of our network. Use our Find a Provider tool to locate a provider in our network.

Service	Description and Limits	Prior Authorization Required by In-Network Providers
Allergy care	Allergy care	Yes, for some services
Ambulance - emergency	Includes ground and emergency helicopter	No
Ambulance - non-emergency	Ambulance transportation from one healthcare facility to another is only covered when it is medically necessary, arranged for and approved by an in-network provider.	Yes, for some services
Behavioral Health	Age limitations may apply. Services include crisis stabilization, inpatient psychiatric hospitalization, outpatient assessment and treatment services, peer support, residential treatment facilities, and rehabilitation services.	Yes, for some services
Chiropractic services	Coverage is limited to manual treatment of the spine and one set of spinal x-rays per year.	Start of care – No Ongoing care – Yes, for some services
Durable Medical Equipment (DME)	Items that are not medically necessary and are not ordered by a provider are not covered.	Yes, in some situations
Drugs: prescription/pharmacy	Use a pharmacy in our network. This can include mail-order pharmacies. Prescription drugs and OTC items approved by the U.S. Food and Drug Administration (FDA).	Yes, for some medications
Drugs: over the counter (OTC)	Over the counter medications require a doctor's prescription.	Yes, for some OTC medications
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)/Well-child exam	Services are for members age 20 and younger. Sports and school physicals annually.	No
Eye care services and eyeglasses	Iowa Health Link members: One complete preventive eye exam every 12 months. At least one pair of eyeglasses every 12 months for ages seven and younger. Ages eight and older, one pair of eyeglasses every 24 months. Hawki members: $100 retail toward eyeglasses every 12 months.	No
Family planning	Family planning services can be from any Medicaid doctor. This includes well-women exams, screening, and pregnancy testing.	No
Foot care	Foot care visits may be limited. Orthotics are covered for some conditions for some eligibility categories.	Yes, in some situations
Hearing aids and services	Hearing aids and services.	Yes, for cochlear implants
High-risk prenatal and infant services	Care management provides special support for members at risk or with special health needs.	Notify plan
Home health care	Care must be prescribed by your doctor. Other conditions apply.	First 4 visits – No Ongoing care – Yes
Hospice Services	Other than an inpatient facility.	Start of care – No Ongoing care – Yes, for some services
Immunizations for children	Available to members age 21 and younger.	No
Inpatient hospital care	Items that are not medically necessary are not covered.	Yes, including observation services
Outpatient hospital care	Items that are not medically necessary are not covered.	Yes, for some services
Lab services and testing	Paternity testing and infertility treatment tests are not covered.	Yes, for some services
Maternity care	See your doctor as soon as you know you are pregnant. Send us the Notice of Pregnancy form at first visit. Prenatal through postpartum services are covered.	Yes, for some services
Nurse midwife services	Covered with all in network providers.	Yes, for non-participating providers
Office visits	Covered with all in network providers.	Yes, for non-participating providers
Orthotics/Prosthetics	Orthotics/Prosthetics are covered for some eligibility categories	Yes
Pain management	Pain services during and after surgery do not require authorization All other pain services do require authorization.	Yes
Physician services	One routine physical exam every 12 months performed by your PCP. Health visits as needed.	No
Private duty nurse services	Overnight nursing services and respite care hours are limited.	Yes
Psychiatric hospital services	Psychiatric hospital services	Yes
Psychiatric services	Psychiatric services	Yes, for some services
Psychological services	Psychological services	Yes, for some services
Radiology and x-rays	Must be ordered by a doctor.	Yes, for high-tech radiology, including CT, MRI, MRA
Reconstructive surgery	Surgery that is performed to make you look better and is determined to be cosmetic is not covered.	Yes
Rehabilitation services	Rehabilitation services	Yes
Skilled Nursing Facility care	Items that are not medically necessary are not covered. This includes private rooms or convenience/comfort items. Some eligibility categories have a limit to total number of days.	Yes
Sterilization services	Sterilizations require informed consent forms 30 days prior to the date of procedures. Hysterectomies are covered on a limited basis.	No
Therapy services. Includes occupational, physical and speech therapies.	Some eligibility categories have limits to total number of visits	Yes, after the first 4 sessions
Stop smoking/ tobacco cessation	Certain medications, patches, or gum to help you stop smoking are covered. Smoking cessation is covered through Tobacco-Free-Iowa. Call 1-800-QUIT-NOW (784-8669) for more information.	No
Surgery	Surgery	Yes, for some services. No authorization required in an emergency
Transplant services	Transplant services	Yes
Urgent care	Urgent care	No

Medically necessary services, as determined by Iowa Medicaid, shall be considered an Iowa Total Care covered service.

See your Member Handbook for more information on:

out-of-network coverage.
coverage outside of our service area.

Do I need a referral to see a specialist?

No. You do not need a referral from the main doctor who takes care of you to see a specialist.

Referrals are not needed for the following types of services:

routine vision care.
chiropractic services.
mental health/counseling services.