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.

Submit a prior authorization request

If prior authorization is required, submit a prior authorization request using the instructions below. All providers are required to submit outpatient and inpatient authorization requests for procedures and services, confirm authorization numbers and check the status of an authorization using the WellSense provider portal. 

For medical services

Log in to our provider portal to submit your prior authorization request online.

Alternatively, you may fax a prior authorization form. This method will result in longer processing times.

New Hampshire Clarity providers must submit prior authorization requests using the provider portal.

 

For other services

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

Check this document to confirm which provider types are managed by Northwood, Inc and which are managed by WellSense. 

Log in to our provider portal to submit your prior authorization request online.

Alternatively, you may fax a prior authorization form. This method will result in longer processing times.

New Hampshire Clarity providers must submit prior authorization requests using the provider portal.

eviCore healthcare

  • Phone: 844-725-4448, prompt #2
  • Fax: 844-545-9213

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. 

Joint surgeries, spine surgeries, and interventional pain management treatments

eviCore healthcare

  • Phone: 844-725-4448, prompt #3 (physical medicine)
  • Fax: 855-774-1319

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.

eviCore healthcare

  • Phone: 888-693-3211, prompt #4 or 844-725-4448, prompt #1
  • Fax: 888-693-3210

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.