[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288598-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-288598-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","prior-authorization-guide-wellcare","Prior Authorization Guide - Wellcare","","Wellcare’s Prior Authorization Guide explains when prior authorization (PA) is required and how providers can submit authorization requests through Availity Essentials and other secure portal or fax options. It outlines PA requirements for PPO vs non-PPO members, urgent authorization and inpatient admission notifications, and timelines for concurrent review. The guide also covers behavioral health emergency services without PA and includes a cardiology management program using Evolent for Medicare members 18+.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/letters/","Letters",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/prior-authorization-guide-wellcare/288598/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/prior-authorization-guide-wellcare/288598.png","ImageObject",442,249,{"name":42,"@type":43},"Eliana","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-18","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":26},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"How can providers determine whether prior authorization is required?","Question",{"text":62,"@type":63},"Use the Pre-Auth Needed tool on Wellcare’s website. Most current information is available within the Pre-Auth tool.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What is the process for urgent authorization requests and inpatient admission notifications?",{"text":67,"@type":63},"Call Provider Services and follow the prompts. 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Availity Essentials is the fastest way to get help with routine tasks. Our current secure Provider Portal will continue to remain active and available to you.  \n| PRIOR AUTHORIZATION (PA) LIST |  |\n| --- | --- |\n| PRIOR AUTHORIZATION (PA) REQUIREMENTS\u003Cbr>Use the Pre-Auth Needed tool on our website to determine if prior authorization is required. This Prior Authorization list is provided as a quick reference. Most current information can be found within the Pre-Auth tool.\u003Cbr>For fastest results, submit requests online at Availity  Essentials or our portal. If the procedure requested meets clinical criteria, the Web provides an approval that can be printed for easy reference. The health plan supports the concept of the Primary Care Physician (PCP) as the “medical home” for its members.\u003Cbr>For members enrolled in a PPO plan, authorization is not required for non-participating providers and facilities, however, services on the medical necessity/ authorization required list below must be covered services within the benefit plan and considered medically necessary for the plan to pay a portion of the out-of-network claim. | For members enrolled in a non-PPO plan, all services rendered by non-participating providers and facilities require authorization, including requests to use the member’s Point-of-Service benefits. Specialists must coordinate all services with the member’s PCP. It is the responsibility of the provider rendering care to verify that the authorization request has been approved before services are rendered.\u003Cbr>Urgent Authorization Requests and Admission Notifications: Call Provider Services and follow\u003Cbr>the prompts. Phone: HMO 1-800-977-7522;\u003Cbr>SNP: 1-877-935-8023 (TTY: 711).\u003Cbr>• Notification is required for Inpatient Hospital admissions by the next business day (except normal maternity delivery admissions) . Phone authorizations must be followed by a fax submission of clinical information.\u003Cbr>• Standard authorization requests may be submitted online or via fax to the numbers listed on the associated forms located here. |\n\n\n| \u003Cbr>BEHAVIORAL HEALTH SERVICES |  |  |  |  |\n| --- | --- | --- | --- | --- |\n|  | SECURE PROVIDER PORTAL\u003Cbr>For Urgent and Inpatient Hospitalization Authorizations and Provider Services:\u003Cbr>Phone: HMO 1-800-977-7522; SNP: 1-877-935-8023 (TTY: 711)\u003Cbr>Please log in to submit your Outpatient Authorization Requests and Inpatient Clinical Submissions. |  |  |  |\n| To obtain authorization, notification of an Inpatient admission is required on the next business day following admission.\u003Cbr>• Inpatient concurrent review is generally done by phone, but a fax option is available and the forms can be found here. Fax: 1-866-900-6918 (Inpatient); 1-855-772-7079 (Outpatient)\u003Cbr>• Psychological testing requests are to be submitted via fax. All other levels of care requiring authorization, including outpatient services, may be submitted online. |  |  |  |  |\n|  | \u003Cbr>Procedures and Services\u003Cbr>Emergency Behavioral Health Services | \u003Cbr>Auth Required\u003Cbr>No | \u003Cbr>Comments |  |\n|  | Non-contracted (non-participating) Provider Services | Yes | All services from non-participating providers require prior authorization.\u003Cbr>*Excluding members enrolled in a PPO plan |  |\n|  | Acute Inpatient Admissions | Yes |  |  |\n|  |  |  |  |  |\n\nNOTE: Please refer to the member ID card to determine appropriate authorization requirements and process.  \nThis guide is not intended to be an all-inclusive list of covered services under the Health Plan.  \n©Wellcare 2026 SHP_ 202512146E  \n4543631_TX5PCARGDEE  \nLast updated: September 2025 Internal Approved 09092025  \n\n| EMERGENCY SERVICES |  |\n| --- | --- |\n| Emergency Services for the following procedures and services do NOT require prior authorization: |  |\n| • Emergency Behavioral Health Services\u003Cbr>• Emergency Care Services | • Emergency Tran","cbCaio45ZYy7hZaG","https://ap.wps.com/l/cbCaio45ZYy7hZaG","pdf",73811,"English","# Prior Authorization (PA) Requirements\n## Behavioral Health Services\n## Emergency Services\n## Cardiology Management Program\n## Inpatient Services & Discharge Planning","[{\"question\":\"How can providers determine whether prior authorization is required?\",\"answer\":\"Use the Pre-Auth Needed tool on Wellcare’s website. Most current information is available within the Pre-Auth tool.\"},{\"question\":\"What is the process for urgent authorization requests and inpatient admission notifications?\",\"answer\":\"Call Provider Services and follow the prompts. Inpatient hospital admissions require notification by the next business day (except normal maternity delivery admissions), and phone authorizations must be followed by a fax submission of clinical information.\"},{\"question\":\"Are emergency services subject to prior authorization?\",\"answer\":\"No prior authorization is required for the listed emergency services, including emergency behavioral health services and emergency care services, as well as emergency transportation services (excluding air and water ambulances) and urgent care services.\"}]","Prior Authorization Guide - Wellcare | PDF"]