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.
For procedures or services
- CPT and HCPCS Code lookup
- Prior authorization matrix (Massachusetts)
- Prior authorization matrix (New Hampshire)
For drug coverage
- Drug formularies and policies
- Prior authorization for prescription drugs
(pharmacy benefit) - Prior authorization for provider-administered drugs
(medical benefit)
Submit a prior authorization request for medical or behavioral health services
To ensure efficient authorizations and timely access to care for our members, use the WellSense provider portal to:
-
Submit prior authorization requests quickly and securely
-
Receive real-time communication and, when applicable, real-time authorization decisions
-
Confirm authorization numbers immediately upon approval
-
Check the status of your requests at any time
Please ensure that all required clinical documentation is submitted at the time of request.
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.
- Massachusetts (MassHealth, Clarity plans)
- New Hampshire Medicaid
- New Hampshire Medicare Advantage
- WellSense prior authorization fax numbers
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
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.
- Massachusetts (MassHealth, Clarity plans)
- New Hampshire Medicaid
- New Hampshire Medicare Advantage
- WellSense prior authorization fax numbers
New Hampshire Clarity providers must submit prior authorization requests using the provider portal.
- 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
Joint surgeries, spine surgeries, and interventional pain management treatments
- 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.
- Phone: 888-693-3211, prompt #4 or 844-725-4448, prompt #1
- Fax: 888-693-3210
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.
You are leaving the WellSense website
You are now leaving the WellSense website, and are being connected to a third party web site. Please note that WellSense is not responsible for the information, content or product(s) found on third party web sites.
By accessing the noted link you will be leaving our website and entering a website hosted by another party. Please be advised that you will no longer be subject to, or under the protection of, our privacy and security policies. We encourage you to read and evaluate the privacy and security policies of the site you are entering, which may be different than ours.