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Prior Authorization Requirements

Exciting News!

We are enhancing our authorization requirements for Medicare.

WellCare is excited to announce some important Medicare outpatient prior authorization requirement changes. We are reducing the overall amount of Medicare outpatient services/procedures requiring prior authorization for Behavioral Health services.  These updates are designed to help ease your day-to-day interactions with us while allowing us to continue to exercise responsible stewardship over the government-funded healthcare programs we administer.  

For dates of service on or after May 26, 2018, we are standardizing Behavioral Health authorization requirements across ALL outpatient places of service for our Medicare services. Listed below are the Behavioral Health outpatient procedure codes that will require prior authorization as of the above-mentioned date.  All other covered procedure codes do not require authorization and can be rendered and billed as medically necessary.

On May 26, 2018, will be updated to reflect these changes. Prior authorization requirements are subject to periodic changes. You should always use our website’s authorization page to determine whether a procedure code requires prior authorization, and always check eligibility and confirm benefits before rendering Behavioral Health services to members. Failure to do so may result in denial of reimbursement. 

For questions regarding this notice, please contact Provider Services at the number located in your Quick Reference Guide. When prompted say “Authorizations” or
press 2.

Thank you for your continued participation and cooperation in our ongoing efforts to render quality healthcare for our members. We look forward to helping you provide the highest quality of care for our members.

Outpatient Procedure Codes Requiring Prior Authorization as of May 26, 2018

90867              Therapeutic Repetitive Transcranial (TMS)

90868              Therapeutic Repetitive Transcranial (TMS)

90869              Therapeutic Repetitive Transcranial (TMS)

90870              Electroconvulsive Therapy

90880              Hypnotherapy

90899              Unlisted Psychiatric procedure

96101              Psychological testing

96102              Psychological testing

96103              Psychological testing

96105              Assessment of Aphasia of speech/language

96116              Neurobehavioral status exam with clinical assessment

96118              Neuropsychological Testing per hour

96119              Neuropsych Testing Admin by Technician per hour

96120              Neuropsych Testing Admin by Computer per occurrence

H0035             Mental health partial hospitalization, treatment, less than 24 hours

H2037             Developmental delay prevention activities, dependent child of client, per 15 minutes

T2027              Specialized child care, waiver; per 15 minutes

T2036              Therapeutic camping, overnight, waiver; each session

T2037  Therapeutic camping, day, waiver; each session

For standard outpatient services, WellCare will continue to use our outlier management practice to monitor and review appropriate utilization of routine outpatient therapy services. This means we will be reviewing your claims data regularly to identify patterns of service that are at variance with your peers. In addition, based on our current member utilization experience we have set a visit threshold of 20 units per year that, if exceeded, will trigger a request for clinical review to determine the medical necessity of additional units.

Procedure codes considered routine include:

90832              Psychotherapy, 30 minutes

90834              Psychotherapy, 45 minutes

90837              Psychotherapy, 60 minutes

90839              Psychotherapy for Crisis, first 60 minutes

90846              Family Psychotherapy, without patient present

90847              Family Psychotherapy, 45 minutes

90849              Multiple-Family Group Psychotherapy

90853              Group Psychotherapy

For psychological and neuropsychological testing, 5 hours will trigger a request for clinical review to determine the medical necessity of additional testing (96101, 96102, 96103, 96116, 96118, 96119, and 96120).

For all HCPC codes (“H” codes), 200 Units Total of all HCPC Series Codes will trigger a request for clinical review to determine the medical necessity of additional HCPC units.

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Last Updated On: 5/3/2018