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Notification - Notify Wellmark within one business day of a member's hospice, home infusion therpay, 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.
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.
Notification
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Voluntary or Mandatory?
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Voluntary
See Requirements effective 1/1/11 for Federal Employee Program (FEP) members under Precertification heading, below)
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| 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:
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Medical and surgical inpatient care
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Critical care admissions
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Hospice admissions
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Home infusion therapy
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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® or MedicareBlue SupplementSM)
- 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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| How to Obtain This Authorization |
Provide the information included on the Notification Form below by calling the Wellmark phone number on the member's ID card, or by returning the completed form via fax (see form for details).
You’ll also find a secure form that can be submitted online via the Notify/Precertify Admissions tool.
Notification Form:
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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.
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| 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)
Before the following admissions for FEP members:
- Hospital inpatient elective emergency 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.
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| How to Obtain This Authorization |
Call the Wellmark phone number on the member's ID card.
For FEP members, call 800-532-1537.
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Prior Approval
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Voluntary or Mandatory?
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Wellmark and FEP - Voluntary
FEP only - Mandatory
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| When to Obtain This Authorization |
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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| How to Obtain This Authorization |
Prior Approval Forms:
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Prior Authorization
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Voluntary or Mandatory?
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(Rx only) - Mandatory
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| 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.
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| How to Obtain This Authorization |
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
| 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 1 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.
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.
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| When to Obtain This Authorization |
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)
Beginning with date of service January 1, 2012. Wellmark no longer requires preauthorization of resting transthoracic echocardiography (TTE), CPT codes 99303-93304 and 93306-93308.
Access a list of 2012 CPT codes  (222KB) that require preauthorization.
Radiology preauthorizations are valid for 60 days from the date of authorization.
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| How to Obtain This Authorization |
By phone:
Call the American Imaging Management (AIM) Call Center at
1-888-800-4497 (M - F, 7:30 AM – 6:00 PM Central)
Request or Check Preauthorizations Online (must have secure web access)
Fact Sheets and Guides
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Treatment Request (for drug-related services)
| Voluntary or Mandatory? |
Voluntary |
| When to Obtain This Authorization |
Before providing treatment, to obtain a medical necessity determination. |
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How to Obtain This Authorization
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Complete the service’s unique Treatment Request.
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