Some Services Require Prior Approval

What if I want to see a doctor or specialist who doesn't accept Well Sense?

In general, you must get all your healthcare services from Well Sense Health Plan network doctors and providers. The only four exceptions are:

  1. If you need emergency care (or treatment at the closest emergency room for serious illness or injury in a life-threatening situation)
  2. If you need urgent care when you are traveling outside our service area
  3. If you need family planning services
  4. If Well Sense Health Plan (or Beacon Health Strategies for behavioral health services) gives prior approval, also called prior authorization, for you to get care from an out-of-network provider

What if I see a doctor who doesn't accept Well Sense Health Plan, will you still cover it?

If you did not receive prior approval, you will be responsible for the costs of your visit, except for the four situations listed above.

What if a treatment I need isn't covered?

Check with your primary care provider and ask him or her to submit a prior authorization request. This is a written statement which tells us why, based on your medical history, we should make an exception and approve the treatment.

We will base our decision on whether there are alternative treatments that should be tried first, and whether this specific treatment is found to be medically necessary (that means a service that is essential to treat your medical condition and keep you healthy).

If I get a non-covered treatment — or don't get prior approval for a treatment that requires it — will you still cover it?

If you didn't receive prior approval, you will be responsible for the costs of your treatment.

What if it is medically necessary for me to get a covered treatment, but there isn't an in-network doctor that can provide it?

You will need to get prior approval before seeing a doctor who isn't part of our network — even if he or she is the only one who can give you covered treatment.

What can I do if my prior authorization request is denied?

You have a right to file and appeal. See the Inquiries, Grievances and Appeal section of your Member Handbook for more information on how to file an appeal.