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Transition of Care (TOC) Authorization Information

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

 

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Last Updated On: 6/18/2021
WellCare will be performing maintenance on Saturday, September 18, 2021 at 6pm EST until Sunday, September 19, 2021 at 6am EST. You might not be able to access systems or fax during this time. We are sorry for any issues this may cause. Thank you for your patience. If you need assistance, contact us. ×