Mga Tagapagbigay

Wellcare Authorization and Appeal Requirements

Wellcare Authorization Requirements

Note: If using the fax option, for fastest results, submit using the associated PA forms found online at Wellcare.com

The following information is required for authorizations:

• Member Name
• Member ID Number
• Provider ID and National Provider Identifier (NPI) number or name of the treating physician
• Facility ID and NPI number or name where services will be rendered (when appropriate)
• Provider and/or facility fax number
• Date(s) of Service
• Diagnosis and Diagnostic Codes
• CPT Codes

Authorization Submission Methods

Via Provider Portal

• As a registered provider, you can submit an authorization request and download or print a summary report for records through the portal

Fax Submission

• Medical Fax: 1-833-562-7172
• Behavioral Health Fax: 1-855-713-0593 | Inpatient: 1-855-713-0592
• Pharmacy Medical Requests Fax: 1-88-871-0564

Urgent Authorization Requests and Admission Notifications: call 1-855-538-0454 and follow the prompts

Authorization Determinations

Standard Organization Determination: determination will be made as expeditiously as the Member’s health condition requires, but no later than 14 calendar days after the Wellcare receives the request for service

Expedited Organization Determination: determination will be made as expeditiously as the Member’s health condition requires, but no later than 72 hours after receiving the Member’s or Provider’s request

Authorization Appeals

• The Provider Portal is the fastest way to submit appeals
• Appeals (non-participating provider and members) is a procedure that deals with the review of adverse initial determinations made by the plan on health care services or benefits
• Reconsiderations (participating providers) is the first step in the appeals process
• Participating Providers have 90 days from the denial date
• Non-Participating Providers have 65 days from the date of notice of the initial determination
• The appeals form can also be faxed with all pertinent medical and supporting documentation to 1-866-01-0657
• Appeals should be submitted via the portal or mailed to the following address:
  • Wellcare
    Attn: Medical Appeals Department
    P.O. Box 31368
    Tampa, FL 33631-3368 

Appeal Submission

• The Provider Portal is the fastest way to submit appeals
• Claim payment disputes for participating providers must be submitted to Wellcare in writing within 90 calendar days of the date of denial of the EOP
• Non-Participating Providers have 60 days from denial date
• Appeals can be faxed to 1-877-277-1808
• Appeals should be submitted via the portal or mailed to the following address:
  • Wellcare Health Plans, Inc
    Attn: Claim Payment Disputes
    P.O. Box 31370
    Tampa, FL 33631-3370

ATTENTION: The Provider Cover Sheet (PDF) must be completed when requesting a formal review of Claim related denials. An appeal, reconsideration or dispute can be submitted using this form.

Definition

Claim Appeal/Reconsideration: A review requested by a member, a member’s representative, or a provider in response to an adverse initial determination made by the health plan

Claim Dispute: A review in response to an adverse initial determination made by the health plan regarding payment of a claim, requested by a provider who is not entitled to a regulated appeals process by federal/state mandate or by their provider contract

Required Information

• Provider Information
• Member Information
• Claim Information
• Reason for Request
• Provider’s Contract Name and Number