Prior authorization

Determine if prior authorization is required

Use the tools below to determine if prior authorization is required for certain procedures, services or drugs.

The provider portal is the preferred method for submitting prior authorization requests. If you must fax your request, use the appropriate form listed below. This method will result in longer processing times.

Behavioral health forms

Applied Behavioral Analysis

Behavioral Health Notification form

Behavioral Health Out of Network prior authorization form

Intensive Home and Community Based Services for Youth

Psychological and Neuropsychological Notification form

Repetitive Transcranial Magnetic Stimulation

Submit a prior authorization request for other services

WellSense partners with Northwood, Inc. to manage prior authorizations for durable medical equipment (DME). For DME requests, providers must contact Northwood, Inc to request authorization prior to providing services.

  • Fax: 877-552-6551
  • Phone: 866-802-6471

Exception: Requests for home infusion therapy services should be submitted through the WellSense provider portal.

MassHealth (Massachusetts Medicaid) plans

  • All gene therapy medication requests must be submitted directly to MassHealth for prior authorization via fax to 877-208-7428.
  • Once MassHealth issues approval for the gene therapy drug, providers must submit a separate prior authorization request to WellSense for the administration codes associated with the therapy.
  • Requests for administration codes should be submitted through the WellSense provider portal. 

MA Clarity, NH Clarity, NH Medicaid, and NH Medicare plans

  • Providers must submit prior authorization requests through the WellSense provider portal.
  • Please ensure that all required clinical documentation is included at the time of submission to support medical necessity for the requested gene therapy and related services.

WellSense partners with eviCore healthcare to manage prior authorization for certain services, including genetic testing, musculoskeletal (MSK) services, and high-tech imaging.

Providers must obtain authorization through eviCore for the following services:

  • Genetic testing
  • Musculoskeletal (MSK) services
  • High-tech imaging, including MRI, CT and PET scans

How to submit a prior authorization request

Providers may submit authorization requests to eviCore using the following methods:

  • Fax: 833-812-0687 
  • Phone: 877-512-5985 (Massachusetts), 866-716-8338 (New Hampshire)

Providers should ensure that all required clinical documentation supporting medical necessity is included with the request to avoid delays in processing.

WellSense partners with Care Continuum (CCUM) to manage prior authorizations for medical drugs when administered by a health care professional or in an outpatient setting.

Check the HCPCS tool to see if a prior authorization is required for a medical drug. Special instructions for providers regarding authorization requirements:

    • MA Medicaid: Authorizations are applicable to members of all ages.
    • MA Clarity: Authorizations are applicable to members 18 years of age and older.
    • NH Medicaid: Authorizations are applicable to members 21 years of age and older.
    • NH Clarity: Authorizations are applicable to members 18 years of age and older.
    • NH Medicare Advantage: Authorizations are applicable to members 18 years of age and older.

Submit your prior authorization request online at eviCore healthcare.

  • Fax: 833-812-0687
  • Phone for
    • Massachusetts members: 877-512-5985
    • New Hampshire members: 866-716-8338
Visit Prior authorizations for provider-administered medications (Buy-and-Bill) for more details. 

Submit your prior authorization request online through an ePA portal

Alternatively, you may request prior authorization by fax or phone. This method will result in longer processing times. Visit Prior authorizations for medications dispensed at a pharmacy for more details.

Vision Services Plan (VSP) 

Appealing a prior authorization decision

If your prior authorization is denied, you or the member may request a member appeal. Use the Appeal Representative Authorization Form to get written permission from the member for you to appeal on their behalf.

For more information on the member appeal process, please reference the prior authorization denial letter or Section 10 of the Provider Manual: Appeals, Inquiries and Grievances.

Peer-to-Peer Requests

Providers may request a Peer-to-Peer discussion with a plan Medical Director to discuss a utilization management determination. Requests must be made within 30 calendar days of the determination date.

Peer-to-Peer discussions do not replace the formal appeal process. If the determination remains unchanged following the discussion, providers may submit an appeal according to the plan’s appeal procedures.