Pre-Service Review Requirements

Wellmark wants to help you avoid unexpected medical bills. Some services or procedures require pre-service review before receiving care.

 

When is a pre-service review needed?

The type of pre-service review depends on the health care services being considered. Click on the links below to learn more about these requirements and what you need to do.

Why does Wellmark have these requirements?


 It's all about doing the right thing about your health care. These requirements make sure you get the right care at the right time, take the right medications, and that the care meets evidenced-based guidelines. We want to ensure that your care is appropriate, timely and safe.

 

 


Authorization Table

The Authorization Table is a resource on Wellmark.com to help you and your provider know Wellmark's pre-service review requirements.

  • Includes a complete list of services, procedures, and equipment that require pre-service approval.
  • Reviewed monthly to determine if updates are necessary based on changing services and procedures that require pre-service review, business circumstances, regulations, and medical research.

 

Prior Approval

 

What it is

Helps to determine if a proposed treatment is medically necessary and follows nationally approved medical guidelines.

When it's needed

Prior approval is required before designated procedures, services or durable medical equipment is provided. Please see the Authorization Table for a complete list of  treatments, procedures, services and supplies that require prior approval.

Why it's important to you

When receiving care from a Wellmark contracting provider in Iowa or South Dakota, the contracting provider will handle the prior approval on your behalf. Therefore, if prior approval does not occur before the service is provided, Wellmark will not pay the provider.

 

If you are receiving care from a nonparticipating provider or nonparticipating provider outside of Iowa or South Dakota, you must make sure that you or your provider contacts Wellmark for approval before you receive services. Otherwise, you will be responsible for the bill.

 

If you or your provider do not request prior approval for a service, the benefit for that service will be denied on the basis you did not request prior approval.

 

Other information that's important to know:

  • Nonparticipating providers in Iowa or South Dakota are not required to handle the prior approval on your behalf. 
  • Always ask your provider if he or she has fulfilled all prior approval requirements before care is given.
  • If the nonparticipating provider has not submitted a prior approval request, call the precertification phone number on your ID card before receiving services.
  • Upon receiving an Explanation of Benefits (EOB) indicating a denial of benefits for failure to request prior approval, you will have the opportunity to appeal and provide us with medical information for our consideration in determining whether the services were medically necessary and a benefit under your medical benefits plan. Upon review, if Wellmark determines the service was medically necessary and a benefit under your medical benefit plan, the benefit for that service will be provided according to the terms of your medical benefits plan.

 

Notification

 

What it is

Notifies Wellmark before you are admitted to the hospital for an inpatient stay (Iowa and South Dakota facilities only).

When it's needed

  • Prior to planned inpatient admissions, with exception of maternity or emergency services.
  • Within one business day of urgent inpatient hospital admissions.
  • Within one business day of discharge.

Please see the Authorization Table for a complete list of services, procedures and supplies that require notification.

Why it's important to you

This requirement is important because it helps Wellmark understand what services you are using so Wellmark's clinical teams can provide help and support when you may need it most. Wellmark will contact the facility to understand what the discharge plans are and assist in creating a support plan that will enable you to be successful after you are discharged. This will help to minimize readmissions or post hospitalization complications. This may include evaluation for home health care services, coordinating follow up appointments, referrals to case management, or referrals to Wellmark's health advocacy service.

 

Other information that's important to know:

  • When receiving care from a Wellmark contracting provider in Iowa or South Dakota, the contracting provider will handle the notification on your behalf.
  • Nonparticipating providers in Iowa or South Dakota are not required to handle the notification on your behalf.
  • Always ask your provider if he or she has fulfilled all notification requirements before care is given.
  • If the nonparticipating provider has not submitted the notification, call the precertification phone number on your ID card before receiving services.

 

Precertification

 

What it is

Helps determine whether a service or admission to a facility is medically necessary.

When it's needed

Please see the Authorization Table for a complete list of services, procedures and supplies that require precertification.

Why it's important to you

Precertification helps Wellmark understand what services you are using so Wellmark's clinical teams can provide help and support when you may need it most. Wellmark will contact the facility to understand and assist in creating a support plan that will enable you to be successful after you are discharged. This will help reduce readmissions or post hospitalization complications. This may include evaluation for home health care services, coordinating follow up appointments, referrals to case management, or referrals to Wellmark's health advocacy service.

 

When receiving care from a Wellmark contracting provider in Iowa or South Dakota, the contracting provider will handle the precertification on your behalf.

 

If you are receiving care from a nonparticipating provider or provider outside of Iowa or South Dakota, you must make sure that you or your provider notifies Wellmark using the precertification phone number on your ID card before you receive services. If you or the provider do not request precertification for a service or admission to a facility, the benefit for that service could be reduced or denied on the basis you did not request precertification. This means you will be responsible for a portion or the entire bill. (This only applies to out-of-state services. If the services are provided by a Wellmark contracting provider, it is provider liability.)

 

Precertification helps Wellmark understand what services you are using so Wellmark's clinical teams can provide help and support when you may need it most. Wellmark can contact the facility to understand what the discharge plans are and assist in creating a support plan that will enable you to be successful after you are discharged to minimize readmissions or post hospitalization complications. This may include evaluation for home health care services, referrals to case management, or referrals to Wellmark's health advocacy service.

 

Other information that's important to know:

  • Nonparticipating providers in Iowa or South Dakota are not required to handle the precertification on your behalf.
  • Always ask your provider if he or she has fulfilled all precertification requirements before care is given.

If the nonparticipating provider has not submitted the precertification, call the precertification phone number on your ID card before receiving services.

 

Wellmark will respond to precertification requests within a defined about of time. Precertification requests must include supporting clinical information to determine if the service or admission is medically necessary. After you receive the service(s), Wellmark may review the related medical records to make sure they document the services outlined in the approved precertification request. The medical records also must support the level of service billed and document that the services have been provided by the appropriate personnel with the appropriate level of supervision.

 

Preauthorization (Radiology)

 

What it is

Obtains authorization for non-emergency outpatient radiology (diagnostic imaging) services received in Iowa or South Dakota.

When it's needed

Preauthorization is required for non-emergency outpatient radiology (diagnostic imaging) services performed in a freestanding imaging center, hospital outpatient setting, or in-office via physician-owned high-tech equipment. Please see the Authorization Table for a complete list of services, procedures, and supplies that require preauthorization. 

Why it's important to you

When receiving care from a Wellmark contracting provider in Iowa or South Dakota, preauthorization is required for non-emergency outpatient radiology (diagnostic imaging) services performed in a freestanding imaging center, hospital outpatient setting, or in-office via physician-owned high-tech equipment.

 

Your health plan benefits require all services to be medically necessary, and preauthorization ensures the medical necessity of a service exists before the service is provided. Once medical necessity is established, the benefits will be payable based on the terms of your health plan contract. Wellmark wants to make sure the care you are receiving is appropriate and agrees with well-established recommended standards of care.

 

Other information that's important to know:

  • The contracting ordering provider in Iowa or South Dakota will handle the preauthorization on your behalf.
  • If prior approval does not occur before the service is provided, the imaging service provider will not be paid.
  • When care is received from a nonparticipating provider or provider outside of Iowa or South Dakota, radiology preauthorization is not required.

 

Prior Authorization (Drugs)

 

What is it

Some drugs require Wellmark's authorization before the prescription can be filled as a covered benefit.

When it's needed

Before select drugs can be filled as a covered benefit, providers will handle the drug prior authorization on your behalf.

Why it's important to you

This requirement encourages appropriate drug use and enhances drug therapy effectiveness. For a list of drugs that require prior authorization, see the Prior Authorization Table.

 

Referrals

 

What is it

A referral is a formal notification process handled by your network provider when you need to receive services from a non-Wellmark Health Plan of Iowa provider.

When it's needed

If you require care that is beyond the scope of services available from a Wellmark Health Plan of Iowa provider, your Wellmark Health Plan of Iowa provider must request a referral to a provider outside the network. This provider should have expertise in diagnosing and treating your specific condition. The referral must be approved by Wellmark prior to receiving services.

 

For chiropractic care, your personal doctor must notify Wellmark of referrals for chiropractic care that goes beyond the first 12 visits. Wellmark must be notified before benefits are allowed.

Why it's important to you

Generally, you will not receive benefits when you visit a non-Wellmark Health Plan of Iowa provider unless you receive a referral from a Wellmark Health Plan of Iowa provider.

 

As part of the process, the provider notifies Wellmark of the referral, and Wellmark approves the referral prior to receiving services. Please be sure to talk with your Wellmark Health Plan of Iowa provider or call Wellmark Customer Service at the phone number on your ID card before scheduling any services.

Utilization Management services may be performed by a vendor.


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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
 
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