Medicare Pre-Auth

DISCLAIMER: 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.

Chiropractic services are handled by ASH.

Oncology/supportive drugs for members age 18 and older need to be verified by Evolent. 

The following services need to be verified by Evolent:

  • Complex imaging, MRA, MRI, PET, and CT scan
  • Musculoskeletal services

Integrated post-acute care management services need to be verified by Tango & WellSky

All Out of Network requests for members in an HMO plan require prior authorization except emergency care, out-of area urgent care or out-of-area dialysis.  

Important Reminder: Effective July 1, 2025, tango and WellSky will be delegated for Skilled Home Health and Post-Acute Facility management services for Wellcare Advantage members. Please direct IRF and LTACH authorizations to WellSky and all Home Health authorizations to tango starting July 1, 2025. Learn more here. 

Prior Authorization at a Glance

Prior Authorization is NOT Required

The following services do NOT require prior authorization:

  • Services rendered in an emergency room or urgent care center
  • Services rendered by a public health or welfare agency
  • Family planning services billed with a contraceptive management diagnosis

Prior Authorization IS Required

The following services REQUIRE prior authorization:

  • Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
  • Admission of a member to an inpatient facility
  • Hospice services
  • Anesthesia services for pain management or dental procedures
  • Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
  • Services rendered by a chiropractor

 

Prior Authorization Check

To submit a prior authorization Login Here