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Medicare Prior Authorization

List effective July 1, 2023

Wellcare requires prior authorization (PA) as a condition of payment for many services.  This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare.

Wellcare is committed to delivering cost effective quality care to our members.  This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.  Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider's responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member's eligibility at the time service is rendered.

NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.

Effective July 1st, 2023, the following are changes to prior authorization requirements:


Service Category

PA Rule

Services

Procedure Codes

Observation

No PA Required

Observation services

Rev code: 762

Surgical procedures

No PA Required

Subcutaneous hormone pellet implantation

11980

Injectable medications

Step therapy

Injectables

J0587, J0588, J1437, J1439, J1443, J1444, J1445, J1449, J1460, J1560, Q0138, Q0139, Q5126, Q5127, Q5128, Q5129, Q5130

PA Required - No Step Therapy

Injection, onabotulinumotxinA, 1 unit

J0585

No PA Required

Injectables

J0897, J1750, J1756, J2916, Q0221

 

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Y0020_WCM_100876E Last Updated On: 5/10/2023