Types of authorizations

Notification

Mandatory.

Notification

When to obtain this authorization

Notify Wellmark:

• Prior to planned inpatient admissions
• Within one business day of urgent inpatient hospital admissions¹
• Within one business day of discharge

This includes the following types of admissions:

• Hospital inpatient care (medical/surgical care, behavioral health, chemical dependency) facilities in Iowa & South Dakota
• Maternity inpatient stays that exceed the two-day vaginal, four-day cesarean delivery time frames
• Extended inpatient stays for newborns

Do not notify Wellmark of these types of admissions:

• Medicare supplement (e.g., Senior Blue^® or MedicareBlue Supplement^SM)
• Obstetrical admissions that do not exceed the two- and four-day delivery timeframes
• Normal inpatient stays for a newborn
• Outpatient procedures, such as colonoscopies

How to obtain this authorization

Providers participating with Wellmark use the Medical Authorization Table to access submission tools.

Providers outside Iowa and South Dakota seeing Wellmark members should log in to their local plan website and navigate to the out-of-state pre-service review information page.

Providers who are not participating with any Blue Cross and Blue Shield plan should call the number on the member's ID card.

Precertification

Mandatory, in order to avoid a reduction in member benefits.

Precertification

When a Wellmark facility or service provider fails to obtain the required precertification or to provide notification on behalf of a Federal Employee Program member, Wellmark is required to apply a $500 benefit reduction. The member cannot be billed for this amount.

All services subject to precertification will also require concurrent review.

When to obtain this authorization

Before you provide these types of care for Wellmark members:

• Home health services
• Skilled nursing facility services
• Hospital inpatient for acute rehabilitation
• Residential inpatient (mental health and chemical dependency
• Hospital inpatient care (medical/surgical care, behavioral health, chemical dependency) outside Iowa and South Dakota (except maternity)
• Maternity inpatient stays that exceed the two-day vaginal, four-day cesarean delivery time frames
• Extended inpatient stays for newborns

Please note: Some group plans may require additional precertification (e.g., behavioral health). Please log in to the Provider Portal to view member benefits.

Before the following admissions for FEP members:

• Hospital inpatient elective admissions (medical/surgical care, behavioral health, chemical dependency
• Hospice services
• Hospital inpatient for acute rehabilitation
• Residential inpatient (mental health and chemical dependency)

FEP also requires notification:

• Within two business days of a hospital admission for emergency care
• Of maternity stays that extend beyond two days for vaginal or four days for cesarean delivery
• Of extended stays for newborns

How to obtain this authorization

Providers participating with Wellmark use the Medical Authorization Table to access submission tools.

Providers outside Iowa and South Dakota seeing Wellmark members should log in to their local plan website and navigate to the out-of-state pre-service review information page.

Providers who are not participating with any Blue Cross and Blue Shield plan should call the number on the member's ID card.

Prior approval

Mandatory for Wellmark and FEP

Prior approval

When to obtain this authorization

Prior approval is required before a prior approval treatment, procedure, service or supply can be provided. Please see the authorization tables for a complete list of services, procedures and supplies that require prior approval. Prior approval is never required for Wellmark members whose primary coverage is with Medicare (this includes members with Medicare Part A only).

For FEP members, please verify prior approval requirements.

Prior approvals are valid for a specific length of time as long as the patient's benefits do not change between the approval date and date of service.

Prior approval is required for all designated services/procedures located on the Authorization Tables. If the prior approval is not approved or not completed prior to the service being provided, the claim will be denied. The provider will receive an authorization number through the prior approval process that must be submitted on all claims associated with the procedure. If the procedure is the primary reason for the hospital stay and the prior approval is not completed or is not approved, the inpatient admission will not be covered.

More than one plan?

Prior approval is required if the patient is covered by Wellmark and:

• Another health plan.
• The Federal Employee Program (FEP) or SelectFirst®.
• Medicare as the secondary payer.
• Another Wellmark plan as a secondary plan.

If the patient is covered by two Wellmark contracts, separate pre-authorizations must be completed for the service.

How to obtain this authorization

Providers participating with Wellmark use the Medical Authorization Table to access submission tools.

Providers outside Iowa and South Dakota seeing Wellmark members should log in to their local plan website and navigate to the out-of-state pre-service review information page.

Providers who are not participating with any Blue Cross and Blue Shield plan should call the number on the member's ID card. Non-Wellmark providers should submit a Prior Approval Medical form based on whether they practice in Iowa or South Dakota.

Drug authorization

Mandatory (drugs only)

Drug authorization

When to obtain this authorization

Before prescribing a medication — Certain drugs require authorization to ensure they are medically necessary and part of a specific treatment plan.

The approval is valid for one year for most drugs.

How to obtain this authorization

Online:

1. Use the drug authorization table to determine if the authorization is needed.
2. Log in to submit the drug authorization request.

By phone:

1. Call 800-600-8065
2. Choose Option 1
3. Most authorizations will be completed in less than 10 minutes
4. Authorization support is available 24 hours a day, seven days a week

By fax:

1. Complete the authorization form online
2. Print and fax the form to 888-836-0730. If the medication is a specialty drug fax to 866-249-6155.
3. An approval or denial will be faxed back to you.

Have the member fill the prescription at any pharmacy that contracts with CVS Caremark^®.

Priority

The priority level of each authorization request helps Wellmark determine which services require immediate attention, thereby serving the needs of our members.

Priority

To help providers understand more clearly when to mark a request as urgent or emergent, please take a moment to review the terms on this page.

Normal: By default, all requests are set to normal priority. Wellmark is required to respond within 10 calendar days for normal priority requests.

Urgent: A situation in which a delay in decision-making could seriously jeopardize the life or health of the member or the member's ability to regain maximum function based on a prudent layperson's judgment or in the opinion of a practitioner, with knowledge of the member's condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. Wellmark will respond to urgent requests within 72 hours for members with Iowa coverage and 24 hours for members with South Dakota coverage.

Emergent: Emergency means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

1. Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;
2. Serious impairment to bodily functions;
3. Serious dysfunction of any bodily organ or part. If it is an emergent medical situation, services should be provided and notification/authorization activities can occur after the fact.

Radiology pre-authorization

Mandatory for patients who have coverage through the following:

Radiology pre-authorization

• Wellmark Blue Cross and Blue Shield of Iowa
• Wellmark Health Plan of Iowa, Inc.
• Wellmark Blue Cross and Blue Shield of South Dakota
• SelectFirst^® members, depending on member's coverage

Note: Some group plans may have group-specific pre-authorization requirements. Please log in to the Provider Portal to view member benefits.

More than one plan?

Pre-authorization is required if the patient is covered by Wellmark and:

• Another health plan.
• The Federal Employee Program (FEP) or SelectFirst.
• Medicare as the secondary payer.
• Another Wellmark plan as secondary plan.

If the patient is covered by two Wellmark contracts, separate pre-authorizations must be completed for the service.

Pre-authorization is not required for:

• Wellmark members whose primary coverage is with Medicare.
• Patients covered by the Federal Employee Program (FEP) unless the patient is also covered (primary or secondary) by a Wellmark health plan.
• Wellmark members receiving out-of-area diagnostic imaging services.

Requirements for patients covered by plans other than Wellmark

Some Blue Cross and Blue Shield Plans require diagnostic imaging pre-authorization for their members who receive out-of-area (BlueCard^®) services.

To locate information for your patient:

• Access medical policies and authorizations for out-of-area members.
• Select the general precertification/pre-authorization information button.
• Enter the member's prefix.

When to obtain this authorization

Obtain pre-authorization before providing non-emergency outpatient diagnostic imaging services performed in a freestanding imaging center, hospital outpatient setting, or in-office via physician-owned high-tech equipment. Please refer to the authorization tables to determine specific procedures subject to prior approval.

How to obtain this authorization

Providers participating with Wellmark use the Medical Authorization Table to access submission tools.

Providers outside Iowa and South Dakota seeing Wellmark members should log in to their local plan website and navigate to the out-of-state pre-service review information page.

Providers who are not participating with any Blue Cross and Blue Shield plan should call the number on the member's ID card.

Treatment request (for drug-related services)

Voluntary

Treatment request

When to obtain this authorization

Before providing treatment, to obtain a medical necessity determination.

How to obtain this authorization

Complete the service's unique treatment request.