Effective August 17, 2026, Pre- and Post-Decision Peer-to-Peer (P2P) discussions will no longer result in reconsideration of inpatient and post-acute care authorization determinations. Any reconsideration of an adverse coverage determination will instead be managed exclusively through the formal appeals process.
The Wellcare Model of Care includes a standard provision stating that “provider peer-to-peer requests are permitted for disagreement with UM clinical decision making.” This language does not supersede Medicare UM or appeal requirements; any P2P process is limited to clarification of clinical rationale rather than decision-making or reconsideration of the determination.
This operational change to the utilization management (UM) process is effective for all Wellcare health plans, including Medicare Advantage and D-SNP plans in all markets.
All coverage determinations will continue to be made in accordance with applicable Medicare coverage criteria and regulatory requirements, including applicable provisions of the Code of Federal Regulations (CFR) governing Medicare Advantage Organization Determinations, including:
- CFR provisions for Organization Determinations: 42 CFR 422.566, 42 CFR 422.101
- CFR provisions for Appeals: 42 CFR 422.578, 42 CFR 422.582, 42 CFR 422.584
- CFR Provisions for Medicare Advantage Dual-Special Needs Plans designated as an Applicable Integrated Plan: 42 CFR 422.629-422.634.
Providers that disagree with an authorization determination should follow the formal appeals process outlined in the adverse determination notification letter. Providers and members retain the right to request reconsideration and submit additional clinical information as part of the appeals process.
Contact your Health Plan Representative for questions regarding this change.
