Provider Toolkit: Prior Authorization Guide

How to Secure Prior Authorization

Pre-Auth Needed Tool

Use the Pre-Auth Needed Tool on marketplace.wellcarenc.com to quickly determine if a service or procedure requires prior authorization.

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, providers are eligible to submit authorization via the secure provider portal.

Submit Prior Authorization

If a service requires authorization, submit via one of the following ways:


SECURE WEB PORTAL
PROVIDER PORTAL
This is the preferred and fastest method.


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
Medical (Outpatient) - 1-833-897-0322
Behavioral Health (Outpatient) - 1-833-538-2372
Medical (Inpatient) - 1-833-897-0322
Behavioral Health (Inpatient) - 1-833-538-2371
Transplant - 1-833-897-0327



Please note:

  1. Emergency services DO NOT require prior authorization.
  2. Services provided by out-of-network providers DO require prior authorization.
  3. Failure to complete the required authorization or notification may result in a denied claim.

Services and Procedures Requiring Prior Authorization

THE FOLLOWING LIST IS NOT ALL-INCLUSIVE

Ancillary Services

Procedures/Services

Inpatient Admissions

  • Air ambulance transport (non-emergent fixed wing airplane)
  • Durable Medical Equipment (DME)
  • Home healthcare services
  • Hospice
  • Furnished medical supplies
  • Orthotics/prosthetics
  • Genetic testing
  • Quantitative urine drug screen
  • Reconstructive surgery
  • Experimental or investigational
  • High Tech Imaging administered by NIA (CT, MRI, PET):
    • Submit requests to RadMD.com
  • Pain management
  • Cardiac and respiratory therapy
  • All inpatient admissions (within 1 business day of admission)
  • Observation stays exceeding 48 hours 
    • Notification is required within 1 business day if admitted
  • Transplants (not including evaluations)
  • Urgent/emergent admissions
  • Partial inpatient, PRTF and/or intensive outpatient programs

All elective/scheduled admission notifications requested at least 5 days prior to the scheduled date of admit including but not limited to:

  • Medical admissions
  • Surgical admissions
  • Hospice care
  • Rehabilitation facilities


LOG INTO OUR SECURE WEB PORTAL

PROVIDER PORTAL

Out-of-Network Services

WellCare of North Carolina offers PPO products which may provide out-of-network benefits depending on plan. Services provided by out-of-network providers may require prior authorization (excluding emergency services) and are subject to out-of-network member cost share.