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Notification - Inform Wellmark within one business day of a member's inpatient hospital admission.
Precertification - Notify Wellmark before providing acute rehabilitation, home health, home infusion therapy, hospice, or skilled nursing care to avoid a reduction in benefits. 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.
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.
| Type of Authorization |
Voluntary or Mandatory? |
When to Obtain This Authorization |
How to Obtain This Authorization |
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Notification
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Voluntary
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After admission - Within one business day of inpatient hospital admissions for:
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Medical and surgical inpatient care
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Critical care admissions
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Maternity inpatient stays that exceed the two-day vaginal, four-day cesarean delivery time frames
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Extended inpatient stays for newborns
Do not notify Wellmark of these types of admissions:
- Medicare Supplement (e.g., Senior Blue®).
- Obstetrical admissions that do not exceed the two- and four-day delivery timeframes, or require an extended inpatient stay for a newborn.
- Outpatient procedures, such as colonoscopies.
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Call the Wellmark phone number on the member's ID card.
Notification Forms:
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Precertification
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Mandatory, in order to avoid a reduction in member benefits (50% or $5,000 for a Wellmark member, and $500 for FEP members)
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Before you provide these types of care:
- Home health
- Home infusion therapy
- Skilled nursing
- Hospice
- Acute rehabilitation
- Hospital inpatient care outside Iowa and South Dakota (except maternity)
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Call the Wellmark phone number on the member's ID card.
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| Prior Approval:
Wellmark and FEP
FEP only |
Voluntary
Mandatory
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Before a treatment, procedure, service or supply has been provided, for a medical necessity determination.
Prior approvals are valid for a specific length of time - usually 6 months - as long as the patient's benefits do not change between the approval date and date of service.
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Prior Approval Forms:
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Prior Authorization
(Rx only)
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Mandatory
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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.
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By phone:
- Call 1-800-600-8065
- Choose Option 1
- Most prior authorizations will be completed in less than 10 minutes
- Prior authorization support is available 24 hours a day, seven days a week
By fax:
- Complete the prior authorization form online
- Print and fax the forms to
- 1-866-884-4345
- 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 Catalyst Rx.
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Radiology Preauthorization - administered by American Imaging Management (AIM) for Wellmark Blue Cross and Blue Shield plans
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Mandatory for patients who have coverage through:
- Wellmark Blue Cross and Blue Shield of Iowa
- Wellmark Health Plan of Iowa, Inc.
- Wellmark Blue Cross and Blue Shield of South Dakota
More than 1 plan?
- If a patient is covered by two Wellmark plans, preauthorization is required for the primary health plan.
- If a patient has another health plan other than a Wellmark plan as primary and the Wellmark plan is secondary, preauthorization is required.
When preauthorization doesn't apply:
Wellmark does not require preauthorization for patients whose primary coverage is with Medicare.
The preauthorization requirement does not apply to your patients covered by:
- Federal Employee Program (FEP)
- SelectFirst®
- Medicare – primary payer
North Carolina and Tennessee Blue Plans
The North Carolina and Tennessee Blue Cross and Blue Shield Plans require diagnostic imaging preauthorization for their members who receive out-of-area (BlueCard®) services. See the following documents for more information:
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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 require preauthorization:
- Computed Tomography (CT) scans, including CT chest
- Computed Tomographic Angiography (CTA) scans, including CTA chest
- Nuclear Cardiology (For example: SPECT scans, cardiolyte stress tests)
- Positron Emission Tomography (PET)
- Magnetic Resonance Imaging (MRI), including MRI upper extremity joint and MRI upper extremity non-joint; MRI lower extremity and MRI pelvis
- Magnetic Resonance Angiography (MRA)
- Echocardiography (stress, resting transthoracic)
Access a list of 2010 CPT codes  (176KB) that require preauthorization.
Radiology preauthorizations are valid for 60 days from the date of authorization.
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By phone:
Call the American Imaging Management (AIM) Call Center at
1-888-800-4497 (M - F, 7:30 AM – 6:00 PM Central)
By fax:
Fax the completed form to AIM at 1-800-610-0050:
Request or Check Preauthorizations Online (must have secure web access)
Fact Sheets and Guides
Learn about the radiology pre-service appeal/post-service inquiry process.
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Treatment Request (for drug-related services)
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Voluntary
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Before providing treatment, to obtain a medical necessity determination.
(View the medical policies associated with drug-related services.)
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Complete the service’s unique Treatment Request.
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