Before you provide any of the treatments, procedures, or services designated, Wellmark requires a prior approval to determine medical necessity. View the Authorization Table for details on which procedures require pre-service review, and refer to the table any time a procedure is planned.
Wellmark is licensed to use InterQual® criteria to guide medical necessity determinations. For services that are not addressed by InterQual criteria, detailed clinical criteria is included in the associated medical policy(s), which will be applied during the medical necessity determination process.
Contracting practitioners can view the InterQual criteria via SmartSheets . DME providers and out-of-state providers can receive the SmartSheets via fax by calling 800-552-3993.
Update: The following procedures will require prior approval for dates of service effective Dec. 15, 2012 (Shoulder Arthrotomy and Arthroscopy will not be part of the December roll-out):
Authorization requests for these procedures will be accepted beginning Dec. 1, 2012, for dates of service Dec. 15, 2012, and after. The new online utilization management tool will be available to complete all prior approval requests after Dec. 15, 2012.
After Feb. 4, 2013, prior approvals will no longer be accepted by fax.
Prior approvals are valid for a specific length of time. If there is a date of service change, it is not necessary to update or complete a new prior approval if the new date of service remains within the defined authorization period. If there is a change in the patient's benefit plan, a new prior approval submission is required.
Below is a list of prior approval procedures and services (more details are included in the Authorization Table):
Laminectomy/Hemi-laminectomy (cervical, thoracic and lumbar)
Small Bowel Transplant