Some services, procedures, tests, and medications require a pre-service review before you receive care. These requirements help ensure your care is appropriate, timely and safe. We also want to help you avoid unexpected medical bills. View the Pre-Service Review List on this page for more details, and always refer to it when a procedure is planned.
Here are the basic requirements for each type of pre-service review:
- Prior Approval follows guidelines widely accepted in the medical community to determine whether a proposed treatment is medically appropriate.
- Notification: Unless the need is urgent, we require you to notify us before being admitted to the hospital. Maternity and emergency services are excluded.
- Precertification helps determine whether a service or facility admission is medically necessary. It also details what services will be provided, so our clinical teams can help you with a support plan.
- Preauthorization (Radiology) is needed for non-emergency outpatient radiology services (also known as diagnostic imaging). It’s performed in a free standing imaging center, hospital outpatient setting, or in-office.
- A referral is a formal notification to Wellmark from your personal doctor when you need medical services from a out-of-network provider or specialist. The referral must be approved by Wellmark prior to you receiving services.
Who is responsible for pre-service review submissions?
- Typically in-network providers complete pre-service reviews for you.
- Out-of-network providers in Iowa or South Dakota are not required to handle the pre-service review on your behalf.
- Always ask your provider if he or she has fulfilled all pre-service review requirements before care is given.
- If the out-of-network provider has not submitted a pre-service review request, call the precertification phone number on your ID card before receiving services.
Why this is important?
If you or the provider do not request pre-service review for a service or admission to a facility, the benefit could be reduced or denied on the basis you did not request a pre-service review. You could be responsible for a portion or the entire bill. (This only applies to out-of-state services. If the services are provided by a Wellmark contracting provider, it’s a provider liability.)
The same goes for prior approval. If you or your provider do not request prior approval for a service, the benefit for that service will be denied on the basis you didn’t request prior approval. Upon receiving your Explanation of Benefits (EOB) indicating the denial, you will have the opportunity to appeal. You’ll be asked to provide medical information to help us determine whether the services were medically necessary and a benefit covered under your medical plan. After review, if Wellmark determines the service was medically necessary and a covered benefit, the benefit will be provided according to the terms of your plan.
Why are notifications and pre-certifications important?
Notifications and pre-certifications help Wellmark understand what services you are using. They also help our clinical teams provide help and support when you may need it most. For instance, if you’ve been admitted to a hospital, we’ll contact the facility to understand your discharge plans and assist in creating a support plan. This may include evaluation for home health care services, coordinating follow up appointments, referrals to case management, or referrals to Wellmark's health advocacy service. Support plans help minimize readmissions and post-hospitalization complications.
Certain specialty medications require prior approval. Visit the Pharmacy Prior Authorization page to access a complete list of those medications, the medical policy associated with each one and a form for making your request.Pharmacy Prior Authorizations
Pre-Service Review ListThis comprehensive list shows when a specific procedure, service, or admission requires pre-service review. Remember:
- Some groups have specific authorization requirements. Always verify your benefits at mywellmark.com.
- Prior approvals are valid for a specific length of time. If there’s a service date change and the new date remains within the defined authorization period, it’s not necessary to update or complete a new prior approval. However, if there’s a change in your benefit plan, a new prior approval submission is required.
- An authorization number is not a guarantee of member benefits. Payment is based on the member's eligibility and plan coverage when the service is provided.
- Applied Behavior Analysis for the Treatment of Autism (South Dakota)
- Abdominoplasty and Panniculectomy
- Air Ambulance (Non-Emergency)
- Allogeneic Stem Cell Transplant
- Autologous Stem Cell Transplant
- Bariatric Surgery
- Bone Growth Stimulation Devices
- Capsule Endoscopy
- Cochlear Implant
- Gender Reassignment (Employer Group Specific)
- Heart Transplant
- Heart/Lung Transplant
- Implantable Bone Conduction Hearing Devices
- Knee Arthroplasty
- Liver Transplant
- Lung and Lobar Transplant
- Mastectomy for Gynecomastia
- Microprocessor Controlled Prostheses for the Lower Limb
- Motorized Wheelchair and Other Power Operated Vehicles
- Myoelectric Prostheses for the Upper Limb
- Negative Pressure Wound Therapy
- Pancreas Transplants (including simultaneous pancreas-kidney, pancreas alone, and pancreas after kidney)
- Percutaneous Neuroblation
- Proton Beam Radiotherapy
- Reduction Mammoplasty
- Small Bowel Transplant
- Small Bowel/Liver and Multivisceral Transplant
- Spinal Fusion
- Surgical Treatment of Obstructive Sleep Apnea
- Treatment of Speech and Language Disorders
- Varicose Vein Treatment
- CT Colonoscopy
- CT Sinus
- CTA Abdomen/Pelvis Combination
- CTA Coronary Arteries
- MRA Head
- MRA Neck
- MRI Abdomen
- MRI Brain
- MRI Breast
- MRI Cardiac
- MRI Cervical Spine
- MRI Lower Extremity
- MRI Lumbar Spine
- MRI Thoracic Spine
- MRI Upper Extremity
- Myocardial Perfusion Imaging
- PET Myocardial Imaging
- PET Tumor/PET Chest
- Stress Echocardiogram
- Acute Inpatient - Out of State
- Home Health Care
- Long Term Acute Care LTAC
- Psychiatric Mental Institution for Children Inpatient (Iowa only)
- Rehabilitation Inpatient
- Residential Inpatient
- Skilled Nursing Facility Inpatient
- Acute Inpatient - In State
- Home Infusion Therapy
Referrals for Out of Network Services