Wellcare by Allwell (Medicare)
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 Medicare Advantage provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
The following services need to be verified by Evolent.
Complex imaging, MRA, MRI, PET, and CT scan
Musculoskeletal services
Oncology/supportive drugs for members age 18 and older need to be verified by New Century Health
Interventional Cardiology services for members 21 years and older need to be verified by Evolent.
Integrated Post-Acute Care Management Services need to be verified by Tango
All out of Network request require Prior Authorization
Except Emergency Care, Urgent Care, or Acute Medical Inpatient Services.
Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network
***NOTE FOR HOME SERVICES***
Authorization is required per 30-day episode of care. Each episode will be reviewed for medical necessity and CMS coverage criteria.
Important Reminder: Effective October 1, 2025 Tango and Wellsky will be delegated for Skilled Home Health and Post-Acute Facility management services for Wellcare Medicare Advantage members. Please direct IRF and LTACH authorizations to WellSky and all Home Health authorizations to tango starting October 1, 2025. Learn more here.
Are services being performed in the Emergency Department or Urgent Care Center, or are the services for dialysis or hospice?
| Types of Services | YES | NO |
|---|---|---|
| IS THE MEMBER BEING ADMITTED TO AN INPATIENT FACILITY? | ||
| ARE ANESTHESIA SERVICES BEING RENDERED FOR PAIN MANAGEMENT, DENTAL SURGERY, OR SERVICES IN THE OFFICE RENDERD BY A NON-PARTICIPATING PROVIDER? | ||
| IS THE MEMBER RECEIVING GENDER REASSIGMENT SERVICES? | ||
| IS THIS AN HMO OUT OF NETWORK SERVICE REQUEST? | ||
| ARE THE SERVICES BEING PERFORMED OR ORDERED BY A NON-PARTICIPATING PROVIDER (PROFESSIONALS/FACILITIES)? |