June 18, 2021
WellCare of North Carolina Medicaid providers are not required to obtain an authorization for professional services (see table below) for the 90-day post-go live period from 7/1/2021 through 9/28/2021. Authorizations will be required for claims processing for services that require an authorization for all dates of service 9/29/2021 and thereafter. Please review our Authorization Look-Up Tool at https://www.wellcare.com/North-Carolina/Providers/Authorization-Lookup for authorization requirements and prepare to submit authorizations on or about 9/1/2021 for those services that require authorization after 9/28/2021.
NC Go Live - TOC Authorization Process
In effect until 9/28/21. Services on or after 9/29/21 WILL require authorizations.
See NC Authorization Lookup Tool at: https://www.wellcare.com/North-Carolina/Providers/Authorization-Lookup
|
Review category |
Review type |
Notification Required |
Auth Required |
Auth Required |
|
|
|
|
In Network |
Out of Network |
|
Pre-certification |
|
|
|
|
|
|
Inpatient (medical) – elective |
N |
Y |
Y |
|
|
Inpatient (medical) – emergency |
N |
Y |
Y |
|
|
Inpatient (BH) |
N |
Y |
Y |
|
|
Inpatient (SUD) |
N |
Y |
Y |
|
|
Inpatient (surgery) – elective |
N |
Y |
Y |
|
|
Inpatient (surgery) - emergency |
N |
Y |
Y |
|
|
Post-acute (SNF, LTACH) |
N |
Y |
Y |
|
|
Comprehensive inpatient rehabilitation facilities (POS 61) |
N |
Y |
Y |
|
Concurrent review |
|
|
|
|
|
|
Inpatient (medical) – elective |
N/A |
Y |
Y |
|
|
Inpatient (medical) – emergency |
N/A |
Y |
Y |
|
|
Inpatient (BH) |
N/A |
Y |
Y |
|
|
Inpatient (SUD)
|
N/A |
Y |
Y |
|
|
Inpatient (surgery) – elective |
N/A |
Y |
Y |
|
|
Inpatient (surgery) - emergency |
N/A |
Y |
Y |
|
|
Post-acute (SNF, LTACH) |
N/A |
Y |
Y |
|
Medical Prior Authorization |
|
|
|
|
|
- Vendor |
|
|
|
|
|
|
Imaging |
N |
N |
N |
|
|
Cardiac services |
N |
N |
N |
|
|
Radiation oncology |
N |
N |
N |
|
|
Surgical services |
N |
N |
N |
|
|
PT/OT/ST |
N |
N |
N |
|
|
Pain procedures |
N |
N |
N |
|
|
Sleep studies |
N |
N |
N |
|
|
Lab (genetic testing/complex lab) |
N |
N |
N |
|
|
|
|
|
|
|
- Non-Vendor |
|
|
|
|
|
|
Outpatient Surgical procedures |
N |
N |
N |
|
|
Office-based procedures |
N |
N |
N |
|
|
DME (See WellCare of NC QRG for DME items that require prior authorization) |
N |
Y |
Y |
|
|
Home Health (nursing) |
N |
Y |
Y |
|
|
Lab |
N |
N |
N |
|
|
Transplant |
N |
N |
N |
|
|
|
|
|
|
|
Behavioral Health Prior Authorization |
|
|
|
|
|
|
BH outpatient services (Medication management, psychiatric and biopsychosocial assessment, individual, group, and family therapies, psychotherapy for crisis, and psychological testing) |
N |
N |
N |
|
|
Diagnostic Assessment |
N |
N |
N |
|
|
Peer Support Services |
Y |
N |
N |
|
|
Mobile Crisis |
Y |
N |
N |
|
|
Professional treatment services in facility-based crisis program |
Y |
N |
N |
|
|
Outpatient Opioid Treatment (billed using H0020) |
Y |
N |
N |
|
|
Ambulatory Detoxification |
Y |
N |
N |
|
|
Non-Hospital Medical Detoxification |
Y |
N |
N |
|
|
Other home-based services (PCS, PDN, BH) |
N |
Y |
Y |
|
|
Medically Supervised or ADATC Detoxification Crisis Stabilization |
Y |
Y |
Y |
|
|
Research-based Intensive Behavioral Health Treatment for Autism Spectrum Disorder |
Y |
Y |
Y |
|
|
Facility-based Crisis Services for Children and Adolescents |
Y |
Y |
Y |
|
|
Partial Hospitalization |
Y |
Y |
Y |
|
|
Psychological services in health departments and school-based health centers sponsored by health departments |
Y |
Y |
Y |
