March 31, 2021
Dear Provider,
Effective July 1, 2021, WellCare Health Plans will be expanding Medicaid in the North Carolina market. We currently are notifying all “New” and “Existing” providers of this expansion and providing awareness of the contracted Vendors that we partner with to provide services.
WellCare currently collaborates with eviCore (CareCore National) to provide prior authorization for certain outpatient procedures. With your support, this collaboration ensures our commitment that members receive medically necessary covered services at the appropriate time and in the appropriate setting.
eviCore is one of WellCare's largest vendors. It provides Utilization Management services for Sleep Management, Musculoskeletal (Pain) Management and Lab Management. eviCore reviews Medical Necessity based on the member's needs through criteria approved by our Medical Policy Committee, which uses evidence-based practice. This lets eviCore:
- Reduce unexplained practice variation and unnecessary visits;
- Promote functionally oriented and measurable treatment programs;
- Focus on skilled, medically necessary treatment interventions; and
- Support patient-centered care founded on best available evidence
All out-of-network requests deemed medically necessary are sent to WellCare for final determination. Any authorizations resulting in a denial from our medical director will result in a letter sent by WellCare. All other letters are sent by eviCore using WellCare's templates.
Clinical review process
If an ordering physician does not receive a medical necessity determination and authorization number from eviCore prior to the non-emergent procedure being performed, then claims may not be reimbursed to the rendering provider. Authorization can be requested directly from eviCore prior to rendering these services, either online or by phone at 1-888-333-8641, Monday-Friday, 7 a.m. to 7 p.m. The preferred method at www.carecorenational.com.
The review criteria utilized by eviCore medical directors have been vetted by an expert physician review board to validate that they are in keeping with published research and guidelines from appropriate specialty societies. The coverage criteria are available at www.carecorenational.com.
Your time is valuable! So please take advantage of eviCore’s online authorization service. It’s quick and easy. Most cases can be completed online within four minutes, while the average phone authorization could take up to 15 minutes. By using the online service, you will avoid unnecessary waiting on the phone. Plus, the online service is available 24 hours a day, seven days a week for your convenience.
To minimize the need for further review by an eviCore clinical nurse or medical director, please have the patient’s chart available when calling so you can easily provide the following:
- Insurance information
- Member information (name, ID number, DOB)
- Ordering or requesting provider information (name, address, TIN/UPIN/NPI)
- Servicing provider information (name, address where test is to be performed)
- CPT and ICD-10 Code
- Patient history including signs and symptoms
- Results of previous studies and treatments as applicable
- Treatment plan
- Lab medical necessity review requires:
- Relevant patient and family history including onset dates
- How test results will be used in this patient's care
Additional information about the program will be posted on our provider website and updated regularly.
Any program changes that impact our provider manual will be communicated via web bulletins and our provider newsletters.
For questions or information about WellCare policy and procedures, please go to www.wellcare.com/NorthCarolina. You can also call a WellCare Medicaid Provider Services representative at 1-866-799-5318, Monday through Saturday from 7 a.m. to 6 p.m.
Thank you for all you do to provide quality care to our members.
Sincerely,
WellCare Health Plans, Inc.
