August 31, 2023
New rules effective October 1, 2023
Prior authorization (PA) is a condition of payment for many services. It is a process initiated by the physician to verify medical necessity of a treatment before it is given to the patient.
- The ordering/prescribing physician is responsible for determining which codes require PA.
- Non-participating providers and facilities require authorization for all services except where indicated.
How to verify if a PA is needed
The complete Medicare Prior Authorization Change Summary list the service categories, services, procedure codes, and the PA rules that indicate whether the category requires or doesn’t require an authorization.
Verify eligibility and benefits
Be sure to verify eligibility and benefits prior to giving services for all members. Payment, regardless of authorization, depends on the member’s eligibility at the time service is rendered. You can check eligibility when you log onto the provider portal at provider.wellcare.com/California.
If you have questions regarding the information contained in this update, contact 866‑999‑3945.
This Information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, and Ancillary Providers.