Contact Us
printer friendly Printer-Friendly Page
Pre-Service Review Requirements

Some services or procedures require approval, notification, precertification or authorization before receiving care, also known as pre-service review. Learn about these requirements and what you need to do.

 

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 Needed

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  treatments, procedures, services and supplies that require prior approval.

How It Works When Care Is Received From a Wellmark Contracting Provider in Iowa or South Dakota

  • The contracting provider will handle the prior approval on your behalf.
  • If prior approval does not occur before the service is provided, the provider will not be paid.

How It Works When Care Is Received From  Nonparticipating Providers or Providers Outside of Iowa or South Dakota

  • 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.
  • If you 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.
  • 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 we determine 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.

When Needed

  • Prior to planned inpatient admissions.
  • 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.

How It Works When Care Is Received From a Wellmark Contracting Provider in Iowa or South Dakota

  • The contracting provider will handle the notification on your behalf.

How It Works When Care Is Received From  Nonparticipating Providers or Providers Outside of Iowa or South Dakota

  • 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 Needed

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

How It Works When Care Is Received From a Wellmark Contracting Provider in Iowa or South Dakota

  • The contracting provider will handle the precertification on your behalf.

How It Works When Care Is Received From a Nonparticipating Providers or Providers Outside of Iowa or South Dakota

  • 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.

 

Preauthorization (Radiology)

What It Is

Obtains authorization for non-emergency outpatient radiology (diagnostic imaging) services.

When 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. 

How It Works When Care Is Received From a Wellmark Contracting Provider in Iowa or South Dakota

  • The contracting ordering provider 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.

How It Works When Care Is Received From a Nonparticipating Providers or Providers Outside of Iowa or South Dakota

  • Radiology preauthorization is not required.

 

Prior Authorization (Drugs)

What It Is

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

When Needed

Before select drugs can be filled as a covered benefit. Review a list of drugs requiring prior authorization.

How It Works When Care Is Received From a Wellmark Contracting Provider in Iowa or South Dakota

  • The contracting provider will handle the drug prior authorization on your behalf.

How It Works When Care Is Received From  Nonparticipating Providers or Providers Outside of Iowa or South Dakota

  • The nonparticipating provider in Iowa or South Dakota will handle the drug prior authorization on your behalf.

 


FacebookTwitterInstagrampinterestLinked InYou Tube