Providers

Exciting Authorization Rule Enhancements

The WellCare Group of Companies has recently reviewed our internal processes for potential enhancements based on your feedback, and as such, we are excited to announce some important outpatient prior authorization requirement changes for our Medicare product. We are reducing the amount of services/procedures requiring prior authorization. In addition, we are reviewing other lines of business and plan to make similar changes in the near future to further simplify and streamline our authorization rules and requirements. These updates are designed to help ease your day-to-day interactions with WellCare while allowing us to continue to exercise responsible stewardship over the government funded health care programs we administer.

For dates of service on or after Aug. 5th, 2017, we are standardizing authorization requirements across ALL outpatient places of service for our Medicare services.

• We have reduced the CPT codes that require an outpatient authorization requirements by over 60%
• Our 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 we have increased some of the thresholds.

We will post a complete list of prior authorization requirements on our website’s authorization page by Aug. 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 Aug. 5th. Prior authorization requirements are subject to periodic changes.  You should always use our website’s authorization page to determine if a procedure requires prior authorization, and always check eligibility and confirm benefits before rendering services to members.  Failure to do so may result in denial of reimbursement.