Change in CareCentrix’s Medical Necessity Review Criteria for Inpatient Rehabilitation Facility (IRF) and Skilled Nursing Facility (SNF) Authorization Requests
Effective Date: 05/01/2026
Wellcare is implementing a change to the medical necessity review criteria used by our delegated vendor, CareCentrix, for IRF and SNF post-acute authorization requests.
What Is Changing
Effective 05/01/2026, authorization requests reviewed by CareCentrix will be reviewed using Centers for Medicare & Medicaid Services (CMS) criteria, rather than InterQual® guidelines, for the following service types:
- Inpatient Rehabilitation Facility (IRF) services
- Skilled Nursing Facility (SNF) services
What Is Not Changing
- Authorization submission processes remain the same.
- Required clinical documentation expectations remain unchanged.
- Review time frames and notification processes are not impacted.
- InterQual® criteria will continue to be used for all other applicable service types.
Why This Change Is Being Made
This update aligns IRF and SNF authorization reviews more closely with CMS coverage requirements and supports greater consistency across post-acute care determinations. The use of CMS criteria for these services ensures alignment with Medicare standards and promotes uniform decision-making across all markets.
Provider Action Required
No immediate action is required. Providers should continue submitting authorization requests to CareCentrix in accordance with existing procedures and ensure that submitted clinical documentation supports medical necessity consistent with CMS guidelines for IRF and SNF services.
Questions
If you have questions regarding this change or require additional clarification, please contact your Provider Relations team.
We appreciate your continued partnership and commitment to providing high-quality care to our members.
