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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.

 

ServiceDescription and LimitsPrior 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.