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New Coding Integrity Guidelines

Medical Benefit Medication Prior Authorization

WellCare Health Plans is committed to continuously improving its medical benefit medication claims review and prior authorization processes. Effective September 1, 2020, we will introduce new Pharmacy Prior Authorization Coding Guidelines based on required authorization standards, coding rules published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT®)  by the American Medical Association (AMA) and ICD-10-CM guidelines governed by Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS).

Please see the table below for the recent updated to the prior authorization guidelines.

HCPCS Code

Prior Auth Required?

Description

J7345

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

J2787

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

J2186

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

J1095

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

J1130

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

J0884

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

Q9991

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

Q9992

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

J9023

Y

This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization to HealthHelp, WellCare’s vendor for prior authorization of this service. Please submit via the HeathHelp website, call 888-210-3736 or fax 888-210-3769

J1627

Y

This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization to HealthHelp, WellCare’s vendor for prior authorization of this service. Please submit via the HeathHelp website, call 888-210-3736 or fax 888-210-3769

J9285

Y

This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization to HealthHelp, WellCare’s vendor for prior authorization of this service. Please submit via the HeathHelp website, call 888-210-3736 or fax 888-210-3769

J9203

Y

This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization to HealthHelp, WellCare’s vendor for prior authorization of this service. Please submit via the HeathHelp website, call 888-210-3736 or fax 888-210-3769

J9022

Y

This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization to HealthHelp, WellCare’s vendor for prior authorization of this service. Please submit via the HeathHelp website, call 888-210-3736 or fax 888-210-3769

J9044

Y

This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization to HealthHelp, WellCare’s vendor for prior authorization of this service. Please submit via the HeathHelp website, call 888-210-3736 or fax 888-210-3769

J7175

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J7179

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J7209

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J7210

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J7211

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J7320

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

Q5105

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

Q5106

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J1428

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

Q5103

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

Q5104

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

Q5108

Y

This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization to HealthHelp, WellCare’s vendor for prior authorization of this service. Please submit via the HeathHelp website, call 888-210-3736 or fax 888-210-3769

Q5110

Y

This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization to HealthHelp, WellCare’s vendor for prior authorization of this service. Please submit via the HeathHelp website, call 888-210-3736 or fax 888-210-3769

Q5111

Y

This medication does require authorization and is primarily used for oncology indications. Please submit prior authorization to HealthHelp, WellCare’s vendor for prior authorization of this service. Please submit via the HeathHelp website, call 888-210-3736 or fax 888-210-3769

J1555

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J1729

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

J1726

N

Medication does not require prior authorization on medical benefit. Please submit claims using appropriate billing information.

J2350

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J0606

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J0604

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J2326

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J3358

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

J0565

Y

This medication requires prior authorization review by the WellCare clinical teams. Please submit prior authorization requests to WellCare via Provider Portal.

Determinations as to whether services are reasonable and necessary for an individual patient should be made on the same basis as all other such determinations: with reference to accepted standards of medical practice and the medical circumstances of the individual case.

The proper reporting of CPT® procedure codes enables WellCare Health Plans to more precisely apply reimbursement guidelines and ensure that an accurate record of patient care history is maintained.

Thank you for helping WellCare Health Plans members live better, healthier lives.

If you have any questions or need further information, please contact your Provider Relations Representative.

PRO_46672E Internal/State Approved 01282020                      NA9PROWEB46672E_000