Higher Level of Care Guidelines
The following tips and guidelines will assist providers with submission of accurate and appropriate service requests that will be successfully approved.
This includes acute inpatient, crisis stabilization units, partial hospitalization services and intensive outpatient programs as covered by the specific contract.
Providers may fax these request forms 24/7 to the number assigned to your contract. Emergency Services do not require prior authorization, but notice is required to facilitate claims payments and determine ongoing treatment. Therefore, Wellcare requests notice of all emergency services within 24 hours.
NOTE: For HLOC Services, Wellcare uses both McKesson InterQual™ criteria and MCG (Milliman Clinical Guidelines) as tools to assist in determining medical necessity for mental health and American Society for Addiction Medicine (ASAM) for substance abuse.
Please be certain that all the necessary information to complete the review has been provided. Incomplete or lack of adequate information will delay the response and in certain circumstances, may result in your request being denied.
Inpatient Concurrent Review:
After the initial authorization is approved, concurrent review is needed for any additional inpatient services. Inpatient concurrent review is done telephonically, though providers may fax updated clinical information to be used in the review. The Wellcare behavioral health licensed clinician will confirm admission data, discuss the plan of treatment, the discharge plan and any treatment barriers. Please be prepared to discuss the following data:
Presenting Situation and Current Clinical Status, including:
- Current precipitant, history of treatment
- Current mental status including risks and safety issues
- Diagnoses: Axis I-V upon admission and changes
- Medical Issues
- Medications: (All) reasons, effects, side effects and changes;
- Plan of treatment to stabilize the crisis, evaluation of changes implemented and effectiveness.
Living Situation and Family/Other Supports
- Where was the member living, can he/she go back, the living situation and conditions, and what kind of support/influence the situation provided.
- The current discharge plan, with updates upon each review;
- Any barriers to discharge and what’s being done to resolve these issues;
- Summary of medications, including quantity provided, prescriptions given and affirmation that any prior authorizations for medications has been obtained;
- A concrete final plan with specific follow-up appointments for medical/behavioral health support that meets requirements. NCQA standards are that appointments are made within seven days;
- Within 24 hours of discharge, the provider must fax the Wellcare discharge form to the number indicated or call in the information to the designated staff member.