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Important Authorization Terms

Notification - Notify Wellmark within one business day of a member's hospice, home infusion therapy, inpatient hospital admission, and discharge.

 

Precertification - Precertification is required for certain types of admissions. Review the distinct differences between precertification requirements for Wellmark members and the requirements for Federal Employee Program (FEP) members. Also precertify admissions to hospitals outside of Iowa or South Dakota.

 

Prior Approval - Receive a medical necessity determination before you administer a treatment, procedure, service or supply.

 

Prior Authorization - Obtain a medical necessity determination before you prescribe certain medications.

 

Priority - The priority level of each authorization request helps Wellmark determine which services require immediate attention, thereby serving the needs of our members. To help providers understand more clearly when to mark a request as urgent or emergent, please take a moment to review the terms on this page.

 

Radiology Preauthorization - Receive approval before providing nonemergency outpatient diagnostic imaging services to avoid a denial of services.

 

Treatment Request - Find out if a drug-related service is medically necessary prior to administering the treatment.

 

Learn about Wellmark's pre-service review requirements by viewing the Authorization Table.

 

Notification

Voluntary or Mandatory?

Mandatory

 

When to Obtain This Authorization

Notify Wellmark:

  • prior to planned inpatient admissions.
  • within one business day of urgent inpatient hospital admissions.
  • within one business day of discharge.

 This includes the following types of admissions:

  • Medical and surgical inpatient care
  • Critical care admissions
  • Hospice admissions
  • Home infusion therapy
  • Maternity inpatient stays that exceed the two-day vaginal, four-day cesarean delivery time frames
  • Extended inpatient stays for newborns

Do not notify Wellmark of these types of admissions:

  • Medicare Supplement (e.g., Senior Blue® or MedicareBlue SupplementSM)
  • Obstetrical admissions that do not exceed the two- and four-day delivery timeframes nor do normal inpatient stays for a newborn
  • Outpatient procedures, such as colonoscopies

Effective Dec. 15, 2012, prior approval is now required for all designated services/procedures located on the authorization table. If the prior approval is not approved or not completed prior to the service being provided, the claim will be denied. The provider will receive an authorization number through the prior approval process that must be submitted on all claims associated with the procedure. If the procedure is the primary reason for the hospital stay and the prior approval is not completed or is not approved, the inpatient admission will not be covered.

How to Obtain This Authorization

Contracted providers should use the Authorization Table.

Non-contracted providers and providers outside of Iowa and South Dakota need to call the number on the member's ID card.

Precertification

Voluntary or Mandatory? 

Mandatory, in order to avoid a reduction in member benefits.

 

When a contracting facility or service provider fails to obtain the required precertification or to provide notification on behalf of a Federal Employee Program member, Wellmark is required to apply a $500 benefit reduction. The member cannot be billed for this amount.

 

All services subject to precertification also will require concurrent review.

When to Obtain This Authorization

Before you provide these types of care for Wellmark members: 

  • Home health
  • Skilled nursing
  • Acute rehabilitation
  • Inpatient behavioral health/chemical dependency depending on member contract; always verify benefits with Wellmark
  • Hospital inpatient care outside Iowa and South Dakota (except maternity)

PLEASE NOTE: Some group plans may require additional precertification (e.g., behavioral health). Please log into the provider portal to view member benefits.

 

Before the following admissions for FEP members:

  • Hospital inpatient elective admissions
  • Skilled nursing
  • Hospice
  • Acute rehabilitation
  • Inpatient behavioral health/substance abuse

FEP also requires notification:

  • within two business days of a hospital admission for emergency care.
  • of maternity stays that extend beyond two days for vaginal or four days for cesarean delivery.
  • of extended stays for newborns.

Effective Dec. 15, 2012, prior approval is now required for all designated services/procedures located on the authorization table. If the prior approval is not approved or not completed prior to the service being provided, the claim will be denied. The provider will receive an authorization number through the prior approval process that must be submitted on all claims associated with the procedure. If the procedure is the primary reason for the hospital stay and the prior approval is not completed or is not approved, the inpatient admission will not be covered.

How to Obtain This Authorization

Call the Wellmark phone number on the member's ID card.

 

For FEP members, call 800-532-1537.

Prior Approval 

Voluntary or Mandatory? 

Wellmark and FEP - Mandatory 

 

When to Obtain This Authorization

Prior approval is required before a prior approval treatment, procedure, service or supply can be provided. Please see the Authorization Table for a complete list of services, procedures and supplies that require prior approval. 

 

For FEP members, please verify prior approval requirements.

 

Prior approvals are valid for a specific length of time as long as the patient's benefits do not change between the approval date and date of service.

 

Effective Dec. 15, 2012, prior approval is now required for all designated services/procedures located on the authorization table. If the prior approval is not approved or not completed prior to the service being provided, the claim will be denied. The provider will receive an authorization number through the prior approval process that must be submitted on all claims associated with the procedure. If the procedure is the primary reason for the hospital stay and the prior approval is not completed or is not approved, the inpatient admission will not be covered.

How to Obtain This Authorization

Wellmark contracted providers should use the Authorization Table.

Non-contracted providers and providers outside of Iowa and South Dakota need to submit a prior approval form:

Prior Authorization

Voluntary or Mandatory? 

(Rx only) - Mandatory

When to Obtain This Authorization

Before prescribing a medication - Certain medications require prior authorization to ensure that a drug is medically necessary and part of a specific treatment plan.

 

The approval is valid for one year for most drugs.

How to Obtain This Authorization

By phone:

  1. Call 800-600-8065
  2. Choose Option 1
  3. Most prior authorizations will be completed in less than 10 minutes
  4. Prior authorization support is available 24 hours a day, seven days a week

By fax:

  1. Complete the prior authorization form online
  2. Print and fax the forms to 866-884-4345
  3. An approval or denial will be faxed back to you by the next business day

 

Have the member fill the prescription at any pharmacy that contracts with Catamaran Rx.

Priority

Normal By default, all requests are set to normal priority. Wellmark is required to respond within 15 calendar days for normal priority requests.
Urgent A situation in which a delay in decision-making could seriously jeopardize the life or health of the member or the member's ability to regain maximum function based on a prudent layperson's judgment or in the opinion of a practitioner, with knowledge of the member's condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. Wellmark will respond to urgent requests within 72 hours for members with Iowa coverage and 24 hours for members with South Dakota coverage.
Emergent Emergency means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (1) Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; (2) Serious impairment to bodily functions; or (3) Serious dysfunction of any bodily organ or part. If it is an emergent medical situation, services should be provided and notification/authorization activities can occur after the fact.

Radiology Preauthorization 

Administered by AIM Specialty Health for Wellmark Blue Cross and Blue Shield plans

 Voluntary or Mandatory? 

Mandatory for patients who have coverage through the following:

  • Wellmark Blue Cross and Blue Shield of Iowa
  • Wellmark Health Plan of Iowa, Inc.
  • Wellmark Blue Cross and Blue Shield of South Dakota
  • SelectFirst® members, depending on member's coverage

More than one plan?

Preauthorization is required if the patient is covered by Wellmark and:

  • Another health plan.
  • The Federal Employee Program (FEP) or SelectFirst®.
  • Medicare as the secondary payer. 

If the patient is covered by two Wellmark contracts, the service needs to be preauthorized under just one of the contracts. You do not need two separate preauthorizations.

 

Preauthorization is not required for:

  • Wellmark members whose primary coverage is with Medicare.
  • Patients covered by the Federal Employee Program (FEP) unless the patient is also covered (primary or secondary) by a Wellmark health plan.
  • Wellmark members receiving out-of-area diagnostic imaging services.
  • Some group plans. Please log into the provider portal to view the Notification Requirements within the member benefits.

Requirements for Patients Covered by Plans Other than Wellmark

Some  Blue Cross and Blue Shield Plans require diagnostic imaging preauthorization for their members who receive out-of-area (BlueCard®) services. To locate information for your patient, access Medical Policies and Authorizations Away from Home. Then:

  • Select the General precertification/preauthorization information button.
  • Enter the member's alpha prefix.
When to Obtain This Authorization

Obtain preauthorization before providing non-emergency outpatient diagnostic imaging services performed in a freestanding imaging center, hospital outpatient setting, or in-office via physician-owned high-tech equipment. Please refer to the Authorization Table to determine specific procedures subject to prior approval.

 

How to Obtain This Authorization

By phone:

Call the AIM Specialty Health Call Center at

1-888-800-4497 (M-F, 7:30 a.m.- 6:00 p.m., Central)

 

Online
Authorization Table (available 24/7/365)

 

Guides
Diagnostic Clinical Guidelines  

Treatment Request (for drug-related services)

Voluntary or Mandatory?  Voluntary
When to Obtain This Authorization Before providing treatment, to obtain a medical necessity determination.
 

How to Obtain This Authorization

 

Complete the service's unique Treatment Request.


Related Information

» Prior Authorization and Treatment Request Forms
» Radiology Pre-Service Appeal/Post-Service Inquiry Process
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