P.O. Box 31366
Tampa, Florida 33631-3336
WellCare Expands Collaboration with CareCore National
Dear Provider:
WellCare Health Plans, Inc. (WellCare) currently collaborates with CareCore National
(CareCore) to provide prior authorization for radiology, cardiology, sleep management and
pain management requests. With your support, this collaboration ensures our commitment
that members receive medically necessary covered services at the appropriate time and in the
appropriate setting.
We are expanding our relationship with CareCore effective December 1, 2014 to include prior
authorization requirements and post-service reviews for the following outpatient procedures
for our Medicaid and Medicare line of business:
FOR MEDICARE
Molecular and Genetic
Laboratory Testing
Radiation Therapy
Authorization for payment will be
required for select Molecular
Pathology Tier 1 and Tier 2 codes
and Multianalyte Assays.
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Examples include testing for:
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BRCA
Long QT Syndrome
Lynch Syndrome
Oncotype DX®
PTEN Associated Conditions
EBRT
Brachytherapy
IMRT
IGRT
Proton Therapy
Stereotactic
Radiosurgery
Outpatient Therapy Services
 Occupational and physical
therapy visits for all
outpatient rehabilitation and
habilitation services
 Authorization will be
required for accurate
payment of claims for a
limited range of CPT and
HCPCS codes used for
these services.
 Authorizations of coverage
will be for multiple dates of
service as indicated and
subject to benefit limits.
Note: Prior authorization is not required for these services when performed in an emergency
room/department, urgent care facility, or during an inpatient stay.
KY025532_PRO_LTR_ENG <CMS/State/Internal> Approved MMDDYYYY
©WellCare 2014 KY_02_14
58759
FOR MEDICAID
Molecular and Genetic Laboratory Testing
Outpatient Therapy Services
Authorization for payment will be required for
select Molecular Pathology Tier 1 and Tier 2
codes and Multianalyte Assays.
 Occupational and physical therapy visits
for all outpatient rehabilitation and
habilitation services
Examples include testing for:
 Authorization will be required for
accurate payment of claims for a limited
range of CPT and HCPCS codes used
for these services.





BRCA
Long QT Syndrome
Lynch Syndrome
Oncotype DX®
PTEN Associated Conditions
 Authorizations of coverage will be for
multiple dates of service as indicated
and subject to benefit limits.
Note: Prior authorization is not required for these services when performed in an emergency
room/department, urgent care facility, or during an inpatient stay.
The clinical review process
Physicians should request authorization directly from CareCore prior to rendering these
services, either online or by phone at 1-888-333-8641, Monday–Friday, 7 a.m. to 7 p.m. The
preferred method is via www.carecorenational.com.
Your time is valuable! So please take advantage of CareCore’s online authorization service.
It’s quick and easy. Most cases can be completed online within four minutes, while the
average phone authorization could take up to 15 minutes. By using the online service, you will
avoid unnecessary waiting on the phone. Plus, the online service is available 24 hours a day,
seven days a week for your convenience.
To minimize the need for further review by a CareCore clinical nurse or medical director,
please have the patient’s chart available when calling so you can easily provide the following:
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Insurance information
Member information (name, ID number, DOB)
Ordering or requesting provider information (name, address, TIN/UPIN/NPI)
Servicing provider information (name, address where test is to be performed)
CPT and ICD-9 Code
Patient history including signs and symptoms
Results of previous studies and treatments as applicable
Treatment plan
Lab medical necessity review requires:
KY025532_PRO_LTR_ENG Internal Approved 10312014
©WellCare 2014 KY_02_14
58759
 Relevant patient and family history including onset dates
 An explanation of how test results will be used in this patient's care
Additional information regarding the program will be posted on our provider website and
updated regularly. Please visit www.wellcare.com/kentucky for more information.
Any program changes that impact our provider manual will be communicated via web bulletins
and our provider newsletters.
If you have any questions, please contact WellCare Network Relations at 1-888-588-9769,
Monday–Friday, 8 a.m. to 8 p.m.
Sincerely,
WellCare Health Plans
Enclosures:
CareCore Fact Sheets:
 Laboratory Management Program
 Radiation Therapy Management Program
 Physical Medicine Management Program
KY025532_PRO_LTR_ENG Internal Approved 10312014
©WellCare 2014 KY_02_14
58759