You can submit outpatient and inpatient authorization requests, confirm authorization numbers and check the status of an authorization on the WellSense provider portal. Register for access today!
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.
- 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.
- 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.
- 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.
- To understand what your patient’s plan covers, reference the Covered Service List for WellSense Health Plan.
- 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.
|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
For behavioral health, durable medical equipment, radiology services, or non-emergency transportation, please contact our partners.
|Behavioral Health||Carelon Behavioral Health||Phone: 866-444-5155|
|Durable Medical Equipment||Northwood, Inc.||
|Outpatient Radiology||evicore healthcare||Phone: 888-693-3211
|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.