Prior Authorization (Part C)

What is prior authorization?

Prior authorization is a process which must be completed before you get some services. Some services must get prior authorization, also called prior approval, before the plan will pay for it. Your doctor will make the request. You can make the request too. We will need medical records and notes from your doctor. Other information that shows why you need the item or service may be needed. Call your doctor if you need this information.

What services require prior authorization?

To get a list of items, services or Part B drugs that require prior authorization, please contact Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan) at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. For out-of-network services you must get prior authorization. You do not need prior authorization for emergencies. Out-of-network urgent care or dialysis does not need prior authorization. If you need to get dialysis services outside of the network area, please call Member Services.

What is the process for getting prior authorization?

You may get prior authorization (or prior approval) by calling Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan). Providers need to send prior authorizations through the web portal, by phone or by fax.

If you ask for a "fast decision," you will be told if we approve the item or service within 72 hours after we get your request and within 24 hours of receipt of your Part B drug request. This is what we call an "expedited review." All other requests will be handled within 14 calendar days for items and services and within 72 hours for Part B drugs. If we find that your health may be in danger, we will hurry your request.

We will tell you what we decide in writing or by telephone. In the case of an emergency, you do not need prior authorization.

Prior authorization is not a guarantee of payment. The plan has the right to review the service(s) for medical need after you receive the service(s). You must be a current member with Wellcare Prime to receive services. Some services have limits. Some benefits have exclusions.

If you have any questions, call Member Services at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

Information on appeals

Standard appeal:

You have the right to appeal if you don’t agree with a decision we make about services or payment. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal for items and services 30 calendar days after we get your appeal or 7 calendar days after we receive your Part B drug appeal. Our decision for items and services might take longer if you ask for an extension or if we need more information about your case. We will tell you if we’re taking extra time and will explain why more time is needed. We cannot take an extension for Part B drug appeal decisions. If your appeal is for payment of a service you have already received, we will give you a written answer within 60 calendar days.

Fast appeal:

For items, services and Part B drugs, you will get an answer within 72 hours after we get your fast appeal. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to 30 calendar days for a decision.

We will give you a fast appeal if a doctor asks for one for you or supports your request. If you ask for a fast appeal without support from a doctor, we will decide if your request requires a fast appeal.  If we don’t give you a fast appeal, we’ll give you an answer within 30 calendar days for items and services and within 7 calendar days for Part B drugs.

How to ask for an appeal with Wellcare Prime

Step 1: You, your authorized representative or your doctor must ask us for an appeal.  Your written request must include:

• Your name;
• Your address;
• Your Wellcare Prime ID number;
• Your reasons for appealing; and
• Your medical records, doctor’s letter or other information that proves why you need the item or service. Call your doctor if you need this information.

You can ask to see the medical records and other documents we used to make our decision before or during the appeal and a copy of the guidelines we used to make our decision at no cost to you.

Step 2: Mail, fax, hand-deliver your appeal or call us.

For a standard appeal:

Mail:
Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
Attn: Appeals and Grievances
7700 Forsyth Blvd.
St. Louis, MO 63105

Telephone: 1-855-735-4398 (TTY: 711)

Fax: 1-844-273-2671

Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

If you ask for a standard appeal by phone, we will send you a letter outlining what you told us.

For a fast appeal:

Telephone: 1-855-735-4398 (TTY: 711)

Fax:  1-844-273-2671

What is prior authorization?

Prior authorization is a process which must be completed before you get some services. Some services must get prior authorization, also called prior approval, before the plan will pay for it. Your doctor will make the request. You can make the request too. We will need medical records and notes from your doctor. Other information that shows why you need the item or service may be needed. Call your doctor if you need this information.

What services require prior authorization?

To get a list of items, services or Part B drugs that require prior authorization, please contact Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan) at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. For out-of-network services you must get prior authorization. You do not need prior authorization for emergencies. Out-of-network urgent care or dialysis does not need prior authorization. If you need to get dialysis services outside of the network area, please call Member Services.

What is the process for getting prior authorization?

You may get prior authorization (or prior approval) by calling Wellcare Prime. Providers need to send prior authorizations through the web portal, by phone or by fax.

If you ask for a "fast decision," you will be told if we approve the item or service within 72 hours after we get your request and within 24 hours of receipt of your Part B drug request. This is what we call an "expedited review." All other requests will be handled within 14 calendar days for items and services and within 72 hours for Part B drugs. If we find that your health may be in danger, we will hurry your request.

We will tell you what we decide in writing or by telephone. In the case of an emergency, you do not need prior authorization.

Prior authorization is not a guarantee of payment. The plan has the right to review the service(s) for medical need after you receive the service(s). You must be a current member with Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan) to receive services. Some services have limits. Some benefits have exclusions.

If you have any questions, call Member Services at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. 

Information on appeals

Standard appeal:

You have the right to appeal if you don’t agree with a decision we make about services or payment. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal for items and services 30 calendar days after we get your appeal or 7 calendar days after we receive your Part B drug appeal. Our decision for items and services might take longer if you ask for an extension or if we need more information about your case. We will tell you if we’re taking extra time and will explain why more time is needed. We cannot take an extension for Part B drug appeal decisions. If your appeal is for payment of a service you have already received, we will give you a written answer within 30 calendar days.

Fast appeal:

For items, services and Part B drugs, you will get an answer within 72 hours after we get your fast appeal. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to 30 calendar days for a decision.

We will give you a fast appeal if a doctor asks for one for you or supports your request. If you ask for a fast appeal without support from a doctor, we will decide if your request requires a fast appeal.  If we don’t give you a fast appeal, we’ll give you an answer within 30 calendar days for items and services and within 7 calendar days for Part B drugs.

How to ask for an appeal with Wellcare Prime

Step 1: You, your authorized representative or your doctor must ask us for an appeal.  Your written request must include:

• Your name;
• Your address;
• Your Wellcare Prime ID number;
• Your reasons for appealing; and
• Your medical records, doctor’s letter or other information that proves why you need the item or service. Call your doctor if you need this information.

You can ask to see the medical records and other documents we used to make our decision before or during the appeal and a copy of the guidelines we used to make our decision at no cost to you.

Step 2: Mail, fax, your appeal or call us.

For a standard appeal:

Mail:

Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
Attn: Appeals and Grievances
PO Box 10450
Van Nuys, CA 91410-0450

Telephone: 1-855-735-4398 (TTY: 711)

Fax: 1-844-273-2671

Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

If you ask for a standard appeal by phone, we will send you a letter outlining what you told us.

For a fast appeal:

Telephone: 1-855-735-4398 (TTY: 711)

Fax:  1-844-273-2671