Changes to Wellmark Pre-Service Review Program

Wellmark Blue Cross and Blue Shield of Iowa and Wellmark Blue Cross and Blue Shield of South Dakota (collectively known as “Wellmark”) have recently made the following three key-changes to the pre-service review program for their members. They have asked that details about these changes be shared with providers in North Carolina who may provide services to BlueCard^®-eligible Wellmark members seeking care within our state:

1)    Prior approvals that were previously recommended are now required.

2)    Three new procedures have been added to the prior approval list.

3)    An authorization table for pre-service review requirements is now available.

Required prior approvals

As of December 15, 2012, prior approval is required in advance of a procedure or service included on Wellmark’s authorization table being provided to a Wellmark member.  If prior approval is required and not completed before an approval-requiring service is provided, all claims associated with that procedure or service will be denied and may be considered part of the member’s liability.

As a courtesy to patients with Wellmark coverage, providers can fax prior approval requests to Wellmark using their online prior approval medical forms available at Wellmark.com.  The provider and member will each receive a letter from Wellmark with the prior approval determination.  If the procedure or service is approved, an authorization number will be included in the letter.  Once received from Wellmark, the authorization number should be included on all claims associated with the procedure or service.  This includes physician, facility, anesthesiology, and all ancillary claims associated with the service or procedure.  By including the authorization number on all associated claims, Wellmark is able to identify claims related to the procedure or service for payment.  Missing authorization numbers on associated claims may result in unintended denials.

Three new procedures added to Wellmark’s prior approval list

As of Dec. 15, 2012, the following three new procedures were added to Wellmark’s prior approval list:

• Hysterectomy
• Laminectomy/hemi-laminectomy (cervical, thoracic, and lumbar)
• Cochlear implants

Wellmark’s authorization table

Wellmark has developed an online authorization table – listing services, procedures, equipment and other information that will help providers and members better understand the requirements for pre-service review.  The authorization table serves as the starting point to determine Wellmark’s pre-service review requirements and includes the following information:

• CPT/HCPC codes and their descriptions (these are searchable fields)
• Indicators (“yes” or “no”) if a pre-service review is required
• Type of pre-service review, such as prior approval, notification, or pre-certification
• Links to the medical policy or SmartSheets™ - SmartSheets help guide providers through the clinical criteria. Out-of-state practitioners can receive copies via fax by calling 1-800-552-3993.

The authorization table is available on the Wellmark.com provider portal, and it does not require a secure password.  Wellmark reviews the authorization table monthly and applies necessary updates based on changing business circumstances, regulations, and medical research.