Prior Authorizations

We require prior authorization before you:

• Perform certain procedures or services
• Prescribe certain drugs
• Send someone to see an out-of-network provider (except for emergency services and urgent care)

To request prior authorization for all behavioral health services, please contact Beacon Health Options at 866-444-5155.

1. Before scheduling a behavioral health service, medical service or procedure, first confirm if the service is covered by Well Sense Health Plan, New Hampshire Medicaid, or one of our partners.
   
   Search prior authorization requirements using:
   
   • CPT Code Lookup Tool
   • HCPCS Code Lookup Tool
   • Prior Authorization Matrix
   Not all services and procedures that require prior authorization may be listed. If you don’t see a service or procedure above, contact us.
2. If the service is for behavioral health (BH), durable medical equipment (DME), or outpatient radiology, after reviewing the prior authorization matrix, please contact our partners (listed in the matrix) with any prior authorization questions.
3. If the service requires authorization, review the medical policies to see if there is a new policy for the service or procedure. You may also call our Provider Service Line.
4. To understand what your patient’s plan covers, reference the Covered Service List for Well Sense Health Plan.
5. Submit a prior authorization request by fax or online.

For Medical Prior Authorization requests, see below.

For behavioral health, durable medical equipment, radiology services, or non-emergency transportation, please contact our partners.

If you believe that it is medically necessary for a member to take a medication restricted under one of our pharmacy programs, please:

1. Check the formulary to see if prior authorization is required for a medication.
   Medicaid members
   Medicare Advantage members
2. If you believe that it is medically necessary for a member to take a medication that is not covered by our pharmacy program: You may submit a coverage review request online through one of these ePA portals: Surescripts, CoverMyMeds, or ExpressPAth.
3. If you do not have access to an ePA system, you can contact 877-417-1839 to submit your request or submit your request by paper with the:
   Medication PA form (for Medicaid)
   Medication PA form (for Medicare Advantage)
   
   Remember: Always view our Pharmacy Policies prior to submitting your coverage review request.

 Once you submit your request:

• If the request meets criteria, WellSense will cover the drug
• If the request is denied, the member and the authorized appeal representative have the right to appeal the decision

Questions?

Contact our Provider Service Center with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

The policies below summarize WellSense criteria for covering specific services. The plan uses policies as a guide to make determinations regarding healthcare coverage and payment. To ensure you are viewing the most recent version of the policy, you may want to clear your browser's cache.

Search Medical Policies

Please note that the member must be eligible for services before mehttp://wellsense-21504636.hs-sites.com/providers/NH/documents-and-forms#medical-policiesdical coverage policies are applied to any claim. As a result, Well Sense Health Plan can not guarantee payment when a member is ineligible or a non-covered benefit is rendered.

1. Search the WellSense Covered Drug List for coverage of specific medications.
   Medicaid members
   Medicare Advantage members
   
   If the Drug List shows that a medication has limitations, you can learn more about them in the Well Sense Medication Guide Book.
2. If you feel it is medically necessary for a member to take a medication that’s not covered, please submit a prior authorization request through an electronic PA portal for the fastest coverage determination.
3. Be sure to check all clinical guidelines before submitting your coverage request.

If you have submitted a prior authorization request for a procedure or service and it is denied, you or the member may request an appeal. If you request an appeal on a member’s behalf, the member will be required to give written permission for you to act as their authorized appeal representative, which will require their signature on this form.

We recommend that you put the appeal in writing along with any additional information for us to consider and send it to us via fax at 617-897-0805 or by mail to:

WellSense Health Plan
ATTN: Appeals and Grievances Department
529 Main Street, Suite 500
Charlestown, MA 02129

The member or the member’s authorized representative may also deliver a written appeal in person to either the address above or our office in Manchester, NH. A member or their authorized representative also has the option to file an appeal orally by calling the Member Services department at the number listed on the back of the member’s ID card.

Appealing Pharmacy Prior Authorization Decisions

If we deny a pharmacy prior authorization request, you or the member have the right to appeal the decision. If you or the member appeal this decision, please submit any additional information that you would like us to consider during the internal appeal process.

For more information on submitting an appeal, see the Provider Manual.