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DMS rescinds approval of WellCare prior‑authorization guidance after TAC concerns
Summary
After the Behavioral Health Technical Advisory Panel recommended rescinding a WellCare prior‑authorization requirement for outpatient therapy, DMS says it retracted the WellCare document on March 19 for additional internal review and flagged problems with requiring pre‑authorization for prolonged therapy codes.
The Medicaid Advisory Committee heard on May 11 that Behavioral Health Technical Advisory Panel members had recommended rescinding a WellCare prior‑authorization policy that would require pre‑approval for certain outpatient therapy services.
"Delaying care or reducing access to clinically recommended care only worsen symptoms," Steve Shannon, presenting the Behavioral Health TAC recommendation, said, urging DMS to rescind WellCare’s requirement for prior authorization for outpatient individual, family and group therapy.
Chelsea Agee of the Department for Medicaid Services’ contract monitoring branch told the MAC that DMS retracted its approval of the WellCare document on March 19 to allow further review. She said prolonged‑therapy code H0004 is an add‑on code typically used based on clinical judgment during a session and that making that code subject to prior authorization is impractical. "The current approach allowing providers up to 24 hours post service to request authorization creates an administrative burden that is not aligned with typical clinical workflows," Agee said.
DMS said the entire WellCare document was retracted pending resubmission and department review; any future changes would be evaluated before approval. DMS staff also said they would review other MCO notices if committee members report additional concerns.
What’s next: WellCare must resend or revise the guidance for DMS review. The MAC’s Behavioral Health TAC will track whether resubmitted documents address concerns about clinical workflow and access to therapy.
