Prior Authorization Requirements
California
Wellcare By Health Net Medicare Advantage
Effective August 1, 2024
The services, procedures, equipment and outpatient pharmaceutics below apply to:
- Wellcare By Health Net Medicare Advantage (MA) PPO and HMO Direct Network1
These are subject to prior authorization (PA) requirements (unless noted as “notification” required only) and guaranteed only as of the time of access to this prior authorization requirements page. For MA PPO plans, PA is recommended, but not required, for out-of-network coverage only.
Member questions – If members have questions regarding the PA list or requirements, refer to the member services number listed on their identification card.
Pre-Auth Check Tool – Confirm whether a specific code requires authorization on the Medicare Pre-Auth page.
Medical necessity – Medical necessity must exist for any plan benefit to be a covered service whether a PA is required or not.
Services that require PA vs. covered services – This PA list is not intended to be a list of covered services. The member’s Evidence of Coverage (EOC) provides a complete list of covered services. EOCs are available to members on the member portal or in hard copy on request. Providers may obtain a copy of a member’s EOC by requesting it from Provider Services.
Eligibility rules and limitations – Providers are responsible for verifying member eligibility through the Provider Services prior to providing care. Even if a service or supply is authorized, eligibility rules and benefit limitations will still apply – all services, procedures, and equipment are subject to benefit plan coverage limitations.
Submit a PA request –
- Send the request via fax or online to Wellcare By Health Net unless stated differently in requirements listed below.
- The Health Net Request for Prior Authorization form must be completed in its entirety.
- Attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request.
- For more submission instructions, see Avoid Processing Delays for Prior Authorization Requests with These Guidelines.
PA timelines –
If the request is for … | Submit prior authorization request: |
|---|---|
Elective inpatient or outpatient services | As soon as the need for service is identified. |
A routine request | At least five business days before a scheduled procedure. |
An urgent request | 72 hours before a scheduled procedure. Emergency services do not require prior authorization. |
1 Direct Network refers to the directly contracted network.
Inpatient Services
Submit a prior authorization request to Wellcare By Health Net unless stated differently in the requirements listed below.
INPATIENT SERVICES | COMMENTS |
|---|---|
Behavioral health or substance abuse facility | Authorized by the Behavioral Health Team |
Hospice | Notification required only. Covered under Original Medicare |
Hospital | Acute inpatient admission, inpatient rehabilitation, Long-Term Acute Care Hospital (LTAC) |
Skilled nursing facility | |
Urgent/emergent admission |
|
Outpatient Procedures, Services or Equipment
Submit a prior authorization request to Wellcare By Health Net unless stated differently in the requirements listed below.
OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT | COMMENTS |
|---|---|
Ablative techniques for treating Barrett’s esophagus and for treatment of primary and metastatic liver malignancies | |
Abortion | |
Ambulance | Non-emergency air transportation |
Anesthesia | For spine manipulation or closed procedure |
Bariatric procedures |
|
Behavioral health and substance abuse | Authorized by the Behavioral Health Team PA not required for office visits Includes:
|
Bronchial thermoplasty | |
Cardiac |
|
Chiropractic care and Acupuncture visits |
|
Chondrocyte implants | |
Clinical trials | Notification required only. Covered under Original Medicare |
Cochlear implants | |
Dermatology (in-office procedures) | Includes:
|
Diagnostic procedures | Radiology:
Advanced imaging:
Cardiac imaging:
|
Drug testing | PA required for all quantitative tests for drugs of abuse |
Durable medical equipment (DME) and supplies | Includes:
|
Ear, nose and throat (ENT) |
|
Enhanced external counterpulsation (EECP) | |
Experimental/investigational services and new technologies | Includes, but is not limited to, those listed in the Investigational Procedures List |
Gastroenterology |
|
Gender reassignment services (Transgender services) | |
Genetic testing | Includes counseling |
Hearing aid | |
Hernia repair | |
Home health services | Includes:
|
Hospice | Notification required only; covered under Original Medicare |
Hyperbaric oxygen therapy | |
Infertility | Includes drug therapy, testing and treatment |
Joint surgeries | |
Laboratory |
|
Maternity | Notification required only at time of first prenatal visit |
Neuro and spinal cord stimulators | |
Neurology |
|
Neuropsychological testing | Authorized by MHN for behavioral health services or Wellcare By Health Net for medical services. |
Occupational and speech therapy |
|
Ophthalmology |
|
Orthognathic procedures |
|
Orthopedic |
|
Orthotics | Design, construction, and attachment of artificial limbs or other systems |
Pain management | Includes:
|
Palliative care | Applies to D-SNP members only |
Physical therapy |
|
Proprietary laboratory analyses | Includes the following CPT® codes: 0457U, 0459U, 0462U, 0468U, 0472U |
Prosthetics | Design, construction, and attachment of artificial limbs or other systems |
Pulmonology |
|
Radiation therapy | Limited to:
|
Reconstructive and cosmetic surgery, services and supplies | Surgery, services and supplies, including, but not limited to:
|
Referrals to nonparticipating providers | Applies to MA HMO only |
Sacral nerve neuromodulation | |
Skin substitutes and biologicals | |
Sleep studies | Surgery and treatment; facility-based sleep studies |
Spinal surgery | Includes, but is not limited to, laminotomy, fusion, diskectomy, vertebroplasty, nucleoplasty, stabilization, and X-Stop |
Transcatheter implantation of wireless pulmonary artery pressure sensor | |
Transplant |
|
Unlisted procedures | Unlisted special service, procedure or report |
Urology |
|
Uvulopalatopharyngoplasty (UPPP) and laser-assisted UPPP | Surgical procedure |
Wound care | Including, but not limited to:
|
Outpatient Pharmaceuticals (Part B Medications)
Medications
- Part B Medications are authorized by Pharmacy Services
OUTPATIENT PHARMACEUTICALS (PART B MEDICATIONS) | |
|---|---|
Biosimilars are required to be used in lieu of branded drugs | |
Medications newly approved by the U.S. Food and Drug Administration (FDA) |
|
New Medicare Part B medication codes issued by the Centers for Medicare & Medicaid Services (CMS) |
|
Part B Medications |
|