All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response
Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network.
Are Services being performed in the Emergency Department or Urgent Care Center, or for Dialysis or Hospice?
|Types of Services||YES||NO|
|Is the member being admitted to an inpatient facility?|
|Are anesthesia services being requrested for pain management, dental surgery or services in the office rendered by a non-participating provider?|
|Is this an HMO Out of Network service request?|
Medicare Prior Authorization
List effective 1/1/2023
Wellcare requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare.
Wellcare is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
For complete CPT/HCPCS code listing, please use the Online Prior Authorization Tool.