Pre-Auth Needed?
Services Requiring Prior Authorization
To verify if a service requires prior authorization use the “Pre-Auth Needed” tool below or call our utilization management department at 1-833-925-2861 with questions. Failure to obtain the required prior authorization or pre-certification will result in a denied claim.
Note: While WellCare of North Carolina by Celtic offers PPO products with out of network benefits in North Carolina, some services require prior authorization, excluding emergency room services. It is the responsibility of the facility in coordination with the rendering practitioner to ensure that an authorization has been obtained for all inpatient and selected outpatient services, except for emergency stabilization services.
Prior authorization for WellCare of North Carolina-Marketplace
ATTENTION: Providers submitting initial authorization for services for WellCare of North Carolina must submit authorization by phone or fax. Once providers receive first claims remittance provider may register with our secure online web portal. Providers much receive a claims payment to register with our online portal.
Phone authorization
- PHONE: 1-833-925-2861
- After normal business hours and on holidays, calls are directed to the plan’s 24-hour nurse advice line. Notification of authorization will be returned by phone, fax or web.
Fax: Authorization Forms
SECURE WEB PORTAL
- PROVIDER PORTAL - Portal may be used to submit authorization following providers receipt of first claims remittance
All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
Vision services, including all services rendered by an Optician, Ophthalmologist or Optometrist need to be verified by Envolve Vision.
Dental Services need to be verified by Envolve Dental.
The following services (identifiable by procedure code search) need to be verified by Evolent: Complex Imaging, MRA, MRI, PET, and CT scans; Speech, Occupational and Physical Therapy services (excluding chiropractor specialty providers – no authorization required); Pain Management, Spinal Cord Stimulators, and Musculoskeletal services for the spine, shoulder, hip and knee.
Note: Services provided by out-of-network providers are subject to out-of-network coverage policies and member cost share limits.
Note: Services related to an authorization denial will result in denial of all associated claims.
Are Services being performed in the Emergency Department or Urgent Care Center, or for Emergent Transportation?
| Types of Services | YES | NO |
|---|---|---|
| Are the services being performed or ordered by a non-participating provider? | ||
| Is the member being admitted to an inpatient facility? | ||
| Are anesthesia services being rendered for dental procedures? | ||
| Are oral surgery services being provided in the office? | ||
| Is the member receiving gender reassignment services? |