Resumption of Utilization Management Policies (Prior Authorization, Concurrent Review, and Retrospective Review) for Behavioral Health Services
Dear Providers and Staff,
Thank you for your continued partnership in serving WellCare of Kentucky Medicaid members. We have some important information to share with you related to recently passed legislation – House Bill (HB) 695.
HB 695, enacted by the 2025 General Assembly, restores utilization management requirements for behavioral health services that were suspended by the Department for Medicaid Services during the COVID pandemic.
In accordance with HB 695, WellCare is re-instating the utilization management requirements that were in place in January 2020 on outpatient behavioral health services, inpatient psychiatric admissions, and psychiatric residential treatment facility admissions. The effective date of this change will impact claims with dates of service 6/25/25 forward. Any claim submitted for a service(s) rendered to a WellCare of Kentucky Medicaid member that requires authorization after 6/25/25, must have the appropriate authorization approval or the claim will deny.
Below are several resources available to confirm our authorization requirements and how to submit an authorization request:
Provider Manual and Quick Reference Guide (QRG):
Our provider manual and QRG provides detailed information and instructions as to where to review our authorization requirements and how to submit authorization requests are found on the WellCare Medicaid Provider Overview page.
Prior Authorization List
WellCare’s list of behavioral health services/codes subject to prior authorization is published under “Authorizations” on the WellCare Medicaid Provider Behavioral Health page.
Authorization Lookup Tool
Searching via WellCare’s Authorization Lookup Tool is a convenient way to learn whether a given code is subject to prior authorization. The tool is available on the secure Provider Portal.
Authorization Not Required for Emergency Services
Authorization is not required for emergency services; however, if the service is an inpatient psychiatric admission, you must send a notice to WellCare by the end of the business day that follows the admission day.
Authorization Required for Non-participating Providers
Effective 6/25/25, authorization is required for services rendered by all non-participating (out-of-network) providers.
Submitting Authorization Requests
Authorization requests, including all supporting clinical documentation, can be submitted through any of the following options:
- WellCare of Kentucky Medicaid Provider Portal
- Kentucky Inpatient Medicaid Fax: 1-877-338-3686
- Outpatient Medicaid Kentucky Fax: 1-877-544-2007
- Availity Essentials–Login or Availity Essentials–Registration, if you are new to Availity
Authorization Forms
WellCare of Kentucky authorization request forms are available on the Medicaid Provider Forms page.
Inpatient Psychiatric Hospitalization Authorizations and Urgent Authorizations Phone
Please call 1-855-620-1861 to request an inpatient psychiatric hospital authorization or to request urgent authorization.
If additional information is needed to complete the medical necessity review related to an authorization request, the WellCare behavioral health utilization team will reach out to you to request it.
Bi-weekly Provider Webinars
We also invite providers to join the bi-weekly provider webinar every other Friday at 1:00 p.m. EST hosted by our Provider Engagement team. These are one-hour meetings where we discuss current key topics, such as utilization management, and other topics requested by providers. To receive an invite to the webinar series, please send an email to Johnie Akers (Provider Engagement) at johnie.akers@wellcare.com.
Again, we thank you for your continued partnership in delivering quality healthcare to our members. If you have any questions regarding this notice, please contact your assigned Provider Engagement Account Manager.