Hospitals and ancillary providers must get prior authorization before providing any medical services to Wellcare members, except for emergency services. If emergency services result in an inpatient hospital stay, hospitals must contact the member’s assigned IPA for authorization. The member’s assigned IPA can be found on the member’s Wellcare ID card.
Failing to get authorizations before providing services may result in payment delays and/or claims payment denials.
CMS Interoperability and Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries
In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS-0057-F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.
The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third-party summaries.
Reports – Calendar Year (CY) 2025:
