Out-of-network referrals are only reimbursed in specific cases, such as emergencies, as required by law, or when prior authorized
When referring members to specialists or other providers for services beyond your scope, it’s crucial to consider the financial implications for the member. Referrals to out-of-network providers are typically not reimbursed except in specific situations, such as emergencies, as required by law, or when prior authorization has been granted.
To help ensure members avoid unnecessary expenses, always prioritize referring them to in-network providers whenever possible. Choosing in-network providers not only helps members avoid potential out-of-pocket costs but also ensures they receive care aligned with their plan’s coverage.
Exceptions for out-of-network referrals
Out-of-network referrals are permitted only under the following conditions:
- Emergency Situations: When immediate care is necessary.
- Legal Requirements: When federal or state law mandates out-of-network care.
- Prior Authorization: When approved in advance by the Plan or the delegated IPA.
If an exception applies, you must contact the Plan Provider Services or the delegated IPA to verify the necessity of the referral and obtain prior authorization.
How to locate a participating provider
To locate a participating provider, use the Find a Provider tool at bit.ly/WC-Find-a-Provider to determine if an out-of-network referral is necessary and request prior authorization.
Additional information
For additional information about referrals, please refer to the provider operations manual, available on the Wellcare website at bit.ly/WC-Operations-Manual.
If you have questions regarding the information contained in this update, contact 866-999-3945.
