Prior Authorization

When is prior authorization required?

We require prior authorization before you:

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

Determine if prior authorization is needed for a service or procedure.
Determine if prior authorization is needed for a prescription.

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

Next Step: Review the medical policies

Determine if a service requires prior authorization

Before scheduling a behavioral health service, medical service or procedure, first confirm if the service is covered by WellSense Health Plan, New Hampshire Medicaid, or one of our partners.

  1. Search prior authorization requirements using:
  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 WellSense Health Plan.
  5. Submit a prior authorization request by fax or online.

Next Step: Submit prior authorization request

How to submit prior authorization requests

For Medical Prior Authorization requests, see below. For Pharmacy Prior Authorization requests, visit Pharmacy Prior Authorization.

Protect PHI. Please double check fax numbers before sending.

Method  Instructions  Contact
Submit Online Log in to our provider portal to submit your prior authorization request online. For Medicaid Questions

For Medicare Questions
Submit by Fax Please attach supporting clinical information with all requests. If you have any questions about this form, please contact the Provider Service Center.

Submit for Medicaid member
Submit for Medicare Advantage member
Medicaid Fax:

Medicare Fax:


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

Service Partner Contact
Behavioral Health Carelon Behavioral Health Phone: 866-444-5155
Durable Medical Equipment Northwood, Inc.

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

Outpatient Radiology evicore healthcare Phone: 888-693-3211
Fax: 888-693-3210
Non-emergency Transportation WellSense Transportation Phone: 844-909-7433 (Medicaid)
Phone: 844-458-6226 (Medicare Advantage)
Vision Services Vision Services Plan (VSP) Phone: 800-877-7195 (Medicaid)
Phone: 855-492-9028 (Medicare Advantage)
Dental Services DentaQuest Phone: (833) 955-336 (Medicare Advantage)


Appealing prior authorization decisions


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.


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.