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Authorization Rule Enhancements

The WellCare Group of Companies recently made enhancements to our Medicare authorization requirements, and we are now making similar changes to prior authorization requirements for our Medicaid plans across the country.  These enhancements are part of a national effort by major national healthcare associations representing providers and payers to improve the prior authorization process*. 

We are pleased to announce that we are reducing the number of Medicaid services/procedures requiring prior authorization across all outpatient locations.  Our goal is to simplify and standardize authorization requirements so that determination of medical necessity is based on clinical criteria regardless of the service location. 

For dates of service on or after March 31, 2018, we are standardizing authorization requirements across ALL outpatient places of service for our Medicaid services.   Additional information will be available on our provider web portal beginning March 15, 2018.  On March 31, 2018, will be updated to reflect these changes. 

To standardize authorizations for all places of services, there was an overall reduction in the number of services and procedures requiring authorization.  However, certain codes may now have prior authorization requirements that previously did not in a particular outpatient location.  Please note that other utilization management thresholds and rules such as high-dollar durable medical equipment (DME) will continue, although we have increased some of those thresholds. 

Prior authorization requirements are subject to periodic changes. You should always use our website’s authorization page to determine if a procedure requires prior authorization, and always check eligibility and confirm benefits before rendering 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 on your Quick Reference Guide, and when prompted, say “Authorizations” or press 2. 

*Learn more information about national efforts in this regard. This PDF document will open in a new window.


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Last Updated On: 8/7/2018