On January 1, 2026, new prior authorization response time requirements will be implemented to align with a change in the Centers for Medicare & Medicaid Services (CMS) authorization processing timeframes.
- Standard prior authorization requests will be completed within 7 calendar days, with a possible extension up to 14 calendar days under certain circumstances.
- Expedited/Urgent prior authorization requests will be completed within the lesser of 72 hours -OR- the current BD turnaround time.
With shorter response times for supporting clinical information requests, all necessary clinical information should be submitted at the time of the authorization request.
Additional Information
- Complete clinicals include Diagnosis, History and Current Condition, Treatment Plan and Interventions, and Relevant Diagnostic Tests.
- Response times can be lessened if all information is submitted with the authorization request.
- Missing clinical information may lead to a denial due to inadequate supporting records.
- Submitting prior authorization requests via the secure Availity portal allows for faster review.
Centene clinical policies and criteria can be found on the Wellcare's Clinical, Payment & Pharmacy Policies webpage. If you have any questions, please contact your Provider Representative. To access their contact information visit Find My Provider Representative.
