Medical Prior Authorization
If a medical service, procedure or durable medical equipment (DME) item is not listed, Wellmark does not maintain a medical policy or criteria for it. Pre-service review is not required and will not be completed. Payment will be based on eligibility and plan coverage when the service is provided.
If a medical service, procedure or DME item is listed but “No” appears in the “Authorization(s) Review Required“ column, Wellmark maintains a medical policy that outlines the criteria which will be applied to the claim when it is received. Authorization(s) review will not be completed.
Authorization(s) review will be completed only if a medical service, procedure or DME item is listed on the Authorization Table and “Yes” appears under “Pre-service Review Required."
If a medical service or procedure, Wellmark will respond within 15 calendar days for normal priority requests. Do not schedule non-emergent procedures prior to receiving an approval.
If a required authorization(s) review request is not approved or not completed prior to the service being provided, the claim(s) will be denied.
If you receive a denial for services that require prior approval (PA), you may follow Wellmark's member and provider inquiry and appeals Secure Site process. If the request is approved, the accompanying authorization number must be submitted on all claims associated with the procedure.
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. Also remember:
- Some groups have specific authorization requirements. Always verify benefits Secure Site first.
- Servicing providers (i.e., facilities or providers listed as the “servicing facility”) who did not originate the request may check its status.
- Learn more if you are a Non-contracted providers or a contracted DME provider.
Note: Wellmark does not require pre-service review for diagnostic imaging services for our members receiving services from providers who do not contract with Wellmark.
Pharmacy Prior Authorization
Drugs indicated as non-formulary cannot be approved through the prior authorization process.
The prescribing provider should contact Wellmark’s Clinical Call Center at 800-600-8065 or refer to the CVS/caremark Prior Authorization Information page to download the Global Prior Authorization Form External Link and fax to 866-249-6155 to request approval for specialty drugs requiring prior authorization. Obtaining the approval in advance will help to prevent delays at the pharmacy.
If the drug is approved, the prescription can be filled at any in-network pharmacy.
Most prescription drugs are limited to a maximum quantity in a single prescription. Federal regulations limit the quantity that may be dispensed for certain medications. If your prescription is so regulated, it may not be available in the amount prescribed by your health care provider.
In addition, coverage for certain drugs is limited to specific quantities per month, benefit year, or lifetime. Amounts in excess of quantity limitations are not covered unless there is prior authorization criteria in place to request additional quantities and approval is granted.
Your patient's benefits certificate, coverage manual, or policy has specific information about his or her plan's prior authorization requirements.