Authorizations and Approvals
Some medical services, procedures, tests and medications require an authorization from insurance 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.
The authorization process
- Your health care provider recommends a procedure that requires an authorization from your insurance.
- Typically, your health care provider will submit the authorization request.
- Always ask your health care provider if they will be submitting the authorization. Out-of-network providers in Iowa or South Dakota typically will submit on your behalf, but are not required to handle the approval process. To view the progress of an authorization, login to myWellmark® and click the Authorizations tab. You’ll be able to view authorizations 24 hours after they’ve been submitted.
- If the provider doesn’t submit the authorization, you can call the phone number on the back of your ID card before you schedule services.
- Wellmark reviews the authorization request.
- Wellmark makes a decision:
- Approved: You will be notified by mail or email of the decision or view the authorization in myWellmark within 24 hours of the decision being made.
- Denied: You and your provider will be contacted via telephone and a letter will be mailed. Appeal instructions will be provided.
Pre-service review list
This comprehensive list shows when a specific procedure, service or admission requires an authorization. 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.
- Abdominoplasty and Panniculectomy
- Adoptive Immunotherapy/Car-T Cell Therapy
- Air Ambulance (Non-Emergency)
- Allogeneic Stem Cell Transplant
- Autologous Stem Cell Transplant
- BRCA1 and BRCA2 Tests
- Bariatric Surgery
- Blepharoplasty
- Bone Growth Stimulation Devices
- Cochlear Implant
- Cranial Remolding
- Custom Fabricated Knee Braces
- Facility Based Sleep Studies
- Gender Affirmation Surgery
- Heart Transplant
- Heart/Lung Transplant
- Implantable Bone Conduction Hearing Devices
- Knee Arthroplasty
- Laminectomy/Hemi-Laminectomy
- Liver Transplant
- Lung and Lobar Transplant
- Lutathera (Lutetium Lu 177 Dotatate)
- Mastectomy for Gynecomastia
- Microprocessor Controlled Prostheses for the Lower Limb
- Motorized Wheelchair and Other Power Operated Vehicles
- Multiple Sleep Latency Testing
- 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
- Rhinoplasty
- Small Bowel Transplant
- Small Bowel/Liver and Multivisceral Transplant
- Speech Generating Devices
- Spinal Fusion
- Subcutaneous Implantable Cardioverter Defibrillator
- Transcranial Magnetic Stimulation (TMS)
- Treatment of Speech and Language Disorders
- Varicose Vein Treatment
- CT Sinus
- CTA Abdomen/Pelvis Combination
- MRA Head
- MRA Neck
- MRI Abdomen
- MRI Brain
- MRI Cardiac
- MRI Cervical Spine
- MRI Lower Extremity
- MRI Lumbar Spine
- MRI Pelvis
- MRI Thoracic Spine
- MRI Upper Extremity
- PET Myocardial Imaging
- PET Tumor/PET Chest
- 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
Notifications
- Acute inpatient services
Referrals
- Out-of-network services
