Skip to main content

Coverage Information

How to Get Services Covered by WellCare

Call your PCP when you need regular care. He or she will send you to see a specialist for tests, specialty care and other covered services that he or she does not provide. Be sure your PCP approves you to see a specialist. We will cover this care. If your PCP does not provide an approved service, ask him or her how you can get it.

Prior Authorization

Prior authorization (or PA for short) means we must approve a service or prescription drug before you can get it. You or your PCP/specialist should contact us to ask for this approval. If we do not approve your request, we will let you know. Plus, we will give you details about how to file an appeal. 

See your member handbook for the list of services that are covered, and which require a PA.

WellCare of South Carolina Plan Documents

Your Member Handbook explains your plan coverage in detail. It includes important information about your benefits, your rights, and key contact addresses and phone numbers.

How to Get an Authorization

Getting Authorization

Type
of
Request
Decision
Time Frame
Who Can
Request One
How to
Request
Standard* 
(for non-emergency
care)
14 calendar days Your provider Call: 1-888-588-9842
Fax: 1-877-297-3112
Expedited/Fast** 
(for urgent care) 
72 hours  Your provider  Call: 1-888-588-9842 
Fax: 1-877-297-3112

*Sometimes we may need more time to make a standard decision. This may be because we need more information and it’s in your best interest. If so, we’ll take up to 14 more calendar days.

**Sometimes we may need more time to make a fast decision. If so, we'll take up to 48 more hours.

There are some instances when a PA is not needed from us:

  • If you move to our plan from another managed care plan or Medicaid fee-for-service and have an existing PA for a medical service, your service will continue until your provider releases you or you complete the treatment
  • If you're taking a prescription for major depression, schizophrenia or bipolar disorder that was prior authorized by your previous managed care plan or Medicaid fee-for-service, we will continue to cover it up to 60 days (from when you become our member)

Services Available Without Authorization

You don’t need approval from us or your PCP for the following services:

  • Dialysis
  • DME purchases under $250 and orthotics and prosthetics under $500
  • Emergency or urgent care services
  • Emergency transportation services
  • Observation services
  • Routine lab tests and X-ray services
  • Select outpatient procedures (please call us for a complete list of these procedures)

Even though you don’t need approval for these services, you will need to pick a network provider. Look through your provider directory to find one. Remember to use our online provider search tool – Find a Provider. When you’ve made your choice, call to set up an appointment. Remember to take your ID card with you.

  • Getting Authorization

    Getting Authorization

    Type
    of
    Request
    Decision
    Time Frame
    Who Can
    Request One
    How to
    Request
    Standard* 
    (for non-emergency
    care)
    14 calendar days Your provider Call: 1-888-588-9842
    Fax: 1-877-297-3112
    Expedited/Fast** 
    (for urgent care) 
    72 hours  Your provider  Call: 1-888-588-9842 
    Fax: 1-877-297-3112

    *Sometimes we may need more time to make a standard decision. This may be because we need more information and it’s in your best interest. If so, we’ll take up to 14 more calendar days.

    **Sometimes we may need more time to make a fast decision. If so, we'll take up to 48 more hours.

    There are some instances when a PA is not needed from us:

    • If you move to our plan from another managed care plan or Medicaid fee-for-service and have an existing PA for a medical service, your service will continue until your provider releases you or you complete the treatment
    • If you're taking a prescription for major depression, schizophrenia or bipolar disorder that was prior authorized by your previous managed care plan or Medicaid fee-for-service, we will continue to cover it up to 60 days (from when you become our member)
  • Services Available Without Prior Authorization

    Services Available Without Authorization

    You don’t need approval from us or your PCP for the following services:

    • Dialysis
    • DME purchases under $250 and orthotics and prosthetics under $500
    • Emergency or urgent care services
    • Emergency transportation services
    • Observation services
    • Routine lab tests and X-ray services
    • Select outpatient procedures (please call us for a complete list of these procedures)

    Even though you don’t need approval for these services, you will need to pick a network provider. Look through your provider directory to find one. Remember to use our online provider search tool – Find a Provider. When you’ve made your choice, call to set up an appointment. Remember to take your ID card with you.

contact-us

Need help? We're here for you.

Contact Us
Last Updated On: 4/20/2021