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Required Authorizations

To serve our members and support the health care system during the rapidly evolving COVID-19 pandemic, Wellmark Blue Cross and Blue Shield has made several changes related to authorizations, including pre-certifications and concurrent review requests.

 

Providers should refer members for care management needs related to COVID-19 by notifying Wellmark at 1-800-552-3993, extension 3727. Wellmark's care management nurses can assist members with a diagnosis of COVID-19. Whether admitted to a facility, transitioning home, or supporting the member at home if under self-quarantine, the nurse will help to ensure essential needs are being met.

 

Notice: The provisions below will expire on April 30, 2021.

 

Prior approval extensions

New Prior Approval Requests

To serve our members and support the health care system during the rapidly evolving COVID-19 pandemic, Wellmark Blue Cross and Blue Shield has made additional changes related to authorizations for required prior approvals for specified surgeries and procedures.

 

Any new prior approval request received on or after November 17, 2020 for the below services, if approved, will have the approval end date extended to 180 days. This process will end on April 30, 2021. Extending the end date will give both providers and members additional time to complete the service without the additional burden of submitting a new request.

  • Abdominal panniculectomy
  • Bariatric surgery
  • Blepharoplasty
  • BRCA testing
  • Cochlear implant
  • Facility-based sleep studies and multiple sleep latency test (MSLT)
  • Gender reassignment surgeries
  • Implantable bone conduction hearing devices
  • Knee arthroplasty
  • Laminectomy/Hemi-laminectomy
  • Percutaneous neuroblation
  • Reduction mammoplasty and mastectomy for gynecomastia
  • Rhinoplasty
  • Speech therapy
  • Spinal fusion
  • Subcutaneous implantable cardioverter defibrillator
  • Transcranial magnetic stimulation
  • Varicose vein treatment

 

Existing Prior Approval Requests For prior approvals for the above services that have been received by November 17, 2020, we will continue to honor the existing 90 day approval date range. To request an extension of the end date for an additional 90 days, please contact Health Services at 1-800-552-3993

 

Precertification and concurrent review requirements suspended

To facilitate inpatient capacity across the health care system during the COVID-19 pandemic, Wellmark had made the following changes for all in-network, eligible Iowa and South Dakota providers from October 23, 2020 through April 30, 2021:

  • Suspension of precertification and concurrent review requirements
  • Suspension of penalties, if applicable

 

Eligible facilities include:

  • Acute rehabilitation
  • Home health
  • Psychiatric medical institution for children (PMIC)
  • Residential treatment centers (RTC)
  • Skilled nursing facility (SNF)

 

Requirements that continue to apply

  • Providers should continue to provide discharge dates and destination information.
  • Acute Facility (hospital)
    • Iowa and South Dakota
      • Notification of admission and discharge is required. Notifications by facilities will allow Wellmark nurses to assist members during their care transitions, including to the home.
    • Out-of-state
      • Precertification of admission and concurrent review, and discharge notification is required.
  • Long Term Acute Care (LTAC)
    • LTAC is not an approved provider type to apply for credentialing and network participation, nor is it a covered benefit, therefore is not applicable.

 

Glossary of terms

  • Concurrent review — requires medical necessity review on an intermittent basis while the member is hospitalized.
  • Notification — notify Wellmark within one business day of a member's inpatient hospital admission or discharge.
  • Precertification — precertification is required for certain types of admissions. Review the distinct differences between precertification requirements for Wellmark members and the requirements for FEP members. Precertification is also required for admissions to hospitals outside Iowa or South Dakota.

 

Federal Employee Program (FEP)


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