Wellcare outpatient prior authorization changes


The Wellcare Group of Companies has recently reviewed their internal processes for potential enhancements based on your feedback, and as such, they have announced some important outpatient prior authorization requirement changes for their Medicare product. They are reducing the amount of services/procedures requiring prior authorization. In addition, they are reviewing other lines of business and plan to make similar changes in the near future to streamline their authorization rules and requirements.

For dates of service on or after August 5th, 2017, they are standardizing authorization requirements across ALL outpatient places of service for their Medicare services.

  • They have reduced the CPT codes that require an outpatient authorization by over 60%.

  • Their outpatient authorization requirements will be applied across all services rendered in all outpatient settings.

  • Other UM thresholds and rules such as high dollar DME claims will continue, although they have increased some of the thresholds.

They will post a complete list of prior authorization requirements on their website’s authorization page (www.wellcare.com/auth_lookup) by August 1st, 2017. This page will link you to your state specific Quick Reference Guide and Auth Look-up Tool, both of which will be updated with these changes on August 5th. Prior authorization requirements are subject to periodic changes. You should always use their authorization page to determine if a procedure requires prior authorization. Please check eligibility and confirm benefits before rendering services to their members. Failure to do so may result in denial of reimbursement.

For questions regarding this notice, please contact Provider Services at the phone number listed below.

Wellcare Health Plans: 8am-6:30pm. 1-855-538-0454

275 Northpointe Pkwy, Suite 50

Amherst, NY 14228

866.234.5017 (Toll-free)

info@pracfirst.com

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