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, log in to myWellmark® and select “Authorizations” under the “Coverage” drop-down menu. 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. To make sure the requested care is medically appropriate, Wellmark often uses criteria published by InterQual®, an external organization that supports evidence-based clinical decision-making. You can request a copy of authorization criteria used for specific treatments.
- Wellmark makes a decision:
- Approved: You will be notified by mail or email of the decision and can view the authorization in myWellmark within 24 hours of the decision.
- 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 is not a comprehensive list of all services requiring a prior approval or pre-service review. For a complete list of services requiring pre-service review and approval, visit the Authorization Table. For a list of drugs that require prior authorization, review the drug authorization list.
Remember:
- Some groups have specific authorization criteria, such as requiring an in-network provider or facility. You can use myWellmark to verify your benefits and provider's network status.
- 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.
To better understand medical authorizations, approvals and referrals, read this article from BlueSM.
For a complete list of services requiring pre-service review and approval, visit the Authorization Table.
- 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
For a complete list of services requiring pre-service review and approval, visit the Authorization Table.
Beginning with dates of service on and after May 1, 2025, Wellmark does not require prior authorization for advanced imaging on claims submitted for commercial members with a primary diagnosis of cancer.
This does not apply to Wellmark Advantage Health Plan® or Federal Employee Program (FEP) members.
Radiology
- CT, CTA (Computed Tomography, Computed Tomography Angiography)
- MRI, MRA (Magnetic Resonance Imaging, Magnetic Resonance Angiography)
- PET (Positron Emission Tomography)
Cardiology
- Cardiac CT
- Cardiac MRI
- Cardiac PET
For a complete list of services requiring pre-service review and approval, visit the Authorization Table.
- Acute Inpatient - Out of State
- Extended home health skilled nursing services, also known as private duty nursing
- Long Term Acute Care LTAC
- Psychiatric Mental Institution for Children Inpatient (Iowa only)
- Rehabilitation Inpatient
- Residential Inpatient
- Skilled Nursing Facility Inpatient
For a complete list of services requiring pre-service review and approval, visit the Authorization Table.
Notifications
- Acute inpatient services
Referrals
- Out-of-network services
- Out-of-network referrals are typically applicable to HMO plans. Learn more about your network.
- Checking your coverage documents is the best way to know what benefits your plan includes.