Providers must obtain prior authorization for certain services and procedures. Authorization requirements are available in the Quick Reference Guide (QRG).
NOTE: Most services rendered by non-participating providers require authorization. Please consult the QRG for details.
Submitting an Authorization Request
The fastest and most efficient way to request an authorization is through our secure Provider Portal, however you may also request an authorization via fax or phone (emergent or urgent authorizations only).
The following information is generally required for all authorizations:
- Member name
- Member ID number
- Provider ID and National Provider Identifier (NPI) number or name of the treating physician
- Facility ID and NPI number or name where services will be rendered (when appropriate)
- Provider and/or facility fax number
- Date(s) of service
- Diagnosis and diagnostic codes
- CPT codes
Via Provider Portal
As a registered provider, you can submit authorization requests and download or print a summary report for your records. Simply log in and follow these instructions.
Not registered on our secure Provider Portal yet? It only takes a few moments to sign up for an account and start benefitting from the many useful features provided.
NOTE: Authorizations may not be visible in the secure Provider Portal until a final disposition has been determined. As a result, you may receive our fax response before seeing the determination online.
Complete the appropriate Wellcare By ‘Ohana Health Plan notification or authorization form for Medicare. You can find these forms by selecting “Providers” from the navigation bar on this page, then selecting “Forms” from the “Medicare” or Medicaid” sub-menu.
Fax the completed form(s) and any supporting documentation to the fax number listed on the form.
Emergent or Urgent Authorizations Only
Authorization requests that are emergent or urgent should be submitted via telephone. Emergent or urgent requests should only be submitted when the standard time frame could seriously jeopardize the member’s life or health. Requests for expedited authorization will receive a determination within three business days. Contact Provider Services at the phone number listed in the Quick Reference Guide (QRG) to request an expedited authorization.
Authorization determinations are made based on medical necessity and appropriateness and reflect the application of Wellcare By ‘Ohana Health Plan's review criteria guidelines.
Authorizations are valid for the time noted on each authorization response. Wellcare By ‘Ohana Health Plan may grant multiple visits under one authorization when a plan of care shows medical necessity for this request.
Failure to obtain the necessary prior authorization from Wellcare By ‘Ohana Health Plan could result in a denied claim. Authorization does not guarantee payment. All services or procedures are subject to benefit coverage, limitations and exclusions as described in applicable plan coverage guidelines.