Wellcare

UTILIZATION MANAGEMENT VENDOR UPDATES

Terming Vendors:

H3 Management Services and Innovista Health Solutions will no longer manage authorizations for Michigan and Ohio Wellcare Medicare plans effective November 1, 2021

New Vendors:

National Imaging Associates (NIA):  Effective October 1, 2021, NIA will manage prior authorizations for physical therapy, occupational therapy, speech therapy, and pain management. Requests for dates of service October 1, 2021 and beyond should be submitted directly to NIA. Impacted providers will receive separate communications on the NIA expansion that include program details.

Utilization Management Process Updates

The following process changes will be in effect November 1, 2021:

Peer to Peer (P2P)

• The P2P number is changing to 1-866-329-7651
• Timeframes will be as follows:
  • Prior Authorization: Request for P2P must be made within 24 hours of receiving of intent to deny
  • Concurrent Review: The provider has 7 days to request a P2P review from the date the denial letter goes out. Denial may be overturned pending the information presented in the P2P if the member remains inpatient at the time of the P2P

Request Submission Options

There will be updates to the request submission process as a result of the changes mentioned above. The grid below outlines submission options by service type, and includes notes of the changes effective November 1, 2021.

For questions about this notice, please refer to the Quick Reference Guide that will be available on November 1, 2021 at Wellcare/Providers. If you have any questions about this notice, please call your Provider Network Development Representative or Provider Services at 855-538-0454.