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