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How to Get Covered Services

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 doesn’t provide. Be sure your PCP approves you to see a specialist. If your PCP does not provide an approved service, ask him or her how you can get it.

Understanding Referrals and Service Authorizations

Referrals

You may see any doctor in our network without a referral. However, some doctors may request a referral from your PCP. We will still cover medically necessary services provided by an in-network provider without a referral.

You may be referred to another provider if:

  • Your PCP does not provide the care or service you need
  • You need to see a specialist

You could be referred for medical tests, treatments or other services.

Are you having trouble getting a referral you think you need? Contact Member Services at 1-866-799-5318.

Service Authorization and Actions

WellCare of North Carolina will need to approve some treatments and services before you receive them. We may also need to approve some treatments or services for you to continue receiving them. This is called preauthorization.

The following treatments and services must be approved before you get them:

  • DME rentals, DME purchases over $250, orthotics and prosthetics over $500
  • Home health services
  • Elective inpatient procedures
  • Inpatient admissions
  • Long-term acute care hospital admissions
  • Inpatient rehabilitation facility admissions
  • Skilled nursing facility admissions
  • Advanced radiology
  • Genetic and reproductive lab testing
  • Investigation and experimental procedures
  • Outpatient therapy services
  • Select outpatient procedures (please contact Member Services at 1-866-799-5318 for specific procedures)
  • Select dental and all orthodontic procedures

Asking for approval of a treatment or service is called a service authorization request. To get approval for these treatments or services you or your provider need to:

  • Contact Member Services at 1-866-799-5318, or
  • Submit a request through the Provider Portal, or
  • Fax an authorization request form to WellCare of North Carolina at 1-866-587-1383

Call Member Services at 1-866-799-5318 (TTY 711), if you have questions about this process. If English is not your first language, we can translate for you. We can also provide written information in other languages. If you need these services, call Members Services. We’re here for you Monday – Saturday, 8 a.m. to 6 p.m.

We will need to provide the following information to review your request for service:

  • Provider ordering services with contact information
  • Provider to provide services with contact information
  • Services requested
  • Place where services will be performed (example: home, provider office, etc.)
  • Dates the services will be provided
  • Appropriate clinical information to support the preauthorization request (example: includes clinical notes, laboratory results and X-ray results)
Do you need more information? See your member handbook.

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Last Updated On: 9/17/2019