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Prior Authorization (PAs)

Sometimes your PCP, or another provider, may need to ask us to approve care before you get a service or prescription. This is called “prior authorization.” Your PCP or provider will contact us for this approval.

Prior authorization is needed for these types of services:

  • Medical supplies and equipment
    • For rented and purchased medical supplies and equipment, only those costing more than $750 need approval
  • Some medical tests done by your PCP or provider
  • Cardiac programs
  • Home health care
  • Therapies (physical, occupational, speech)
  • Inpatient, including surgical procedures, certain behavioral health outpatient services, and residential behavioral health services.

If we do not approve a prior authorization request, we’ll let you know. If we do not approve a request, and you still receive the service, the provider cannot bill you unless you agreed to pay for it in writing. If prior authorization is denied, you can ask for an appeal. If you still are not happy once the appeal is complete, you can ask for a State Fair Hearing. 

WellCare of Nebraska 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.

This document includes all of your covered services and their co-pay amounts.

How to Get an Authorization

Prior Authorization "How To"

Type
of
Request
Decision
Time Frame
Who Can
Request One
Standard* 
(for non-emergency
care)
Within 14 calendar days Your provider
Expedited/Fast** 
(for urgent care) 
Within 72 hours  Your provider 

*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 business days.

**Sometimes we may need more time to make a fast decision. If so, we’ll take up to14 days. If we do this, we will justify a need for additional information. We will also document how the extension is your best interest.

Please note: After we get all needed information, we will make decisions for services that have already been provided within 30 calendar days. We will send a letter to you and your provider to tell you our decision. (You may ask us to give you information another way and we will communicate with you in the way you prefer.)

Services Available Without a Referral or Authorization (Self-Referral Services)

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

  • Direct access to in-network women’s health specialists for routine and preventive health care services
  • Emergency/urgent care
  • Family planning (any health plan provider)
  • Well-child visits for children age 20 or younger
  • Routine vision care
  • One women’s health visit to an in-network OB/GYN provider each year
  • Post-stabilization services
  • Visits to your PCP

Even though you don’t need approval for these services, you will need to see a provider in our network. You can find a provider using our online Find a Provider search tool you can use our mobile app, MyWellCare. When you’ve made your provider choice, call to set up an appointment. Remember to take your ID cards with you.

  • Getting Authorization

    Prior Authorization "How To"

    Type
    of
    Request
    Decision
    Time Frame
    Who Can
    Request One
    Standard* 
    (for non-emergency
    care)
    Within 14 calendar days Your provider
    Expedited/Fast** 
    (for urgent care) 
    Within 72 hours  Your provider 

    *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 business days.

    **Sometimes we may need more time to make a fast decision. If so, we’ll take up to14 days. If we do this, we will justify a need for additional information. We will also document how the extension is your best interest.

    Please note: After we get all needed information, we will make decisions for services that have already been provided within 30 calendar days. We will send a letter to you and your provider to tell you our decision. (You may ask us to give you information another way and we will communicate with you in the way you prefer.)

  • Services Available Without a Referral or Authorization (Self-Referral Services)

    Services Available Without a Referral or Authorization (Self-Referral Services)

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

    • Direct access to in-network women’s health specialists for routine and preventive health care services
    • Emergency/urgent care
    • Family planning (any health plan provider)
    • Well-child visits for children age 20 or younger
    • Routine vision care
    • One women’s health visit to an in-network OB/GYN provider each year
    • Post-stabilization services
    • Visits to your PCP

    Even though you don’t need approval for these services, you will need to see a provider in our network. You can find a provider using our online Find a Provider search tool you can use our mobile app, MyWellCare. When you’ve made your provider choice, call to set up an appointment. Remember to take your ID cards with you.

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Last Updated On: 8/28/2018