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 upon eligibility covered benefits, provider contracts and 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.
We have separate fax numbers for Medicaid and Medicare pre-authorizations. Please make sure you use the correct fax number to expedite your request. Medicare FAX: 1-877-687-1183. If your request is for a Medicaid recipient, please use this number: Medicaid FAX: 1-866-467-1316.
All Out of Network requests require prior authorization except emergency care, out-of-area urgent care or out-of-area dialysis. Please use the forms below to request prior authorizations.
Medical Forms
- Medicare Inpatient Prior Authorization Request Form (PDF)
- Medicare Outpatient Prior Authorization Request Form (PDF)
- Request for Medicare Prescription Drug Coverage Determination form (PDF)
- Requesting Electronic Prescription Drug Prior Authorization Using CoverMyMeds® (PDF)
Behavioral Health Forms
- Medicare Outpatient Treatment Request Form (PDF)
- Medicare Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)
- Medicare Neuropsych Testing Authorization Request Form (PDF)
- Medicare Outpatient Psychological Testing Authorization Request Form (PDF)
View a list of services that require prior authorization (PDF).
View a list of Medicare Part B medications/agents that require step therapy (MCPB.ST.00 Step Therapy) (PDF).
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
CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries
In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.
Reports:
- Wellcare CMS Final Rule 0057-F Prior Authorization Requirements: H8189 (PDF)
- Wellcare Prior Authorization Metrics Summary: H8189 (PDF)
The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.