Skip to Main Content

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.

Submission Options

Type of Service

Entity

Portal Link

Contact Info

Radiology, Cardiology

National Imaging Associates (NIA)

www1.radmd.com

Phone: 800-424-5388

Sleep studies, genetic testing

eviCore

www.evicore.com

Phone: 888-333-8641

Musculoskeletal surgical procedures

TurningPoint

www.tpshealth.com

Phone: 877-659-9496 Fax: 313-915-5036

Medical oncology, radiation therapy

HealthHelp

portal.healthhelp.com

Phone: 888-210-3736

Pharmacy

Wellcare

provider.wellcare.com

Phone: 833-857-0923 Fax: 888-871-0564

Behavioral Health -Inpatient

Wellcare

provider.wellcare.com

Phone: 855-538-0454

Fax: 855-713-0592

Behavioral Health -Outpatient

Wellcare

provider.wellcare.com

Phone: 855-538-0454

Fax: 855-713-0593

UPDATES – EFFECTIVE OCTOBER 1, 2021:

PT, OT, ST, Pain Management

NIA

www1.radmd.com

Phone: 800-424-5388

UPDATES – EFFECTIVE NOVEMBER 1, 2021:

Inpatient medical requests

Wellcare

provider.wellcare.com

Phone: 855-538-0454

Fax: 855-776-9464

All other outpatient  medical requests

Wellcare

provider.wellcare.com

Phone: 855-538-0454

Fax: 888-361-5684

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.