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Providers urge DMS review after WellCare requires rapid retroactive authorization for extended therapy
Summary
Providers told the Behavioral Health TAC that WellCare's Feb. 1 policy requiring prior authorization (PA) requests for extended therapy sessions (H0004 add-on) within one business day after the service has clinical and administrative consequences; WellCare and DMS said they will review notice methods and documentation requirements.
Sheila Shuster, chair of the Behavioral Health Technical Assistance Committee and a Kentucky Mental Health Coalition representative, brought an item from Michelle Sanborn about a WellCare prior-authorization change that took effect Feb. 1. Michelle Sanborn said providers are receiving denials when they bill the H0004 add-on for extended individual therapy and that the insurer's notice appeared to reference substance-use disorder only even though DMS approved the requirement for all diagnoses.
"I'm very concerned that they're requiring a prior auth for a service that's already been completed," Sanborn said, arguing that asking clinicians to request authorization within one business day risks clinical harm because therapists must make rapid, sometimes unpredictable decisions during sessions.
Providers and case managers described real-world scenarios where clinicians spent hours managing crises and then had to seek retroactive authorization for a 15-minute add-on, and they warned that the administrative burden could prompt clinicians to cut sessions short or absorb the cost. "If the service is already provided for a child, why would we have to, within 24 hours, request a prior auth for something that's already been completed," Sanborn said.
Beth, a WellCare representative on the call, said the company implemented the code change effective Feb. 1 and will expand how it notifies providers (beyond website posting). "We did allow for retro through the end of February," she said, and acknowledged communication problems; she also said WellCare will review feedback about whether the one-business-day window is appropriate.
Justin Daringer of the Department for Medicaid Services said DMS is aware that after-the-fact authorizations exist on the medical side (for example, some inpatient and dental codes) and offered to compile examples and timelines of other codes that permit retroactive PAs. "Medicaid is forbidden by federal law to pay for anything that's not medically necessary," Daringer said, adding that DMS will look into parity between medical and behavioral health handling of after-the-fact authorizations.
Several TAC members asked DMS and WellCare to clarify the documentation required for H0004 (treatment plan vs. recent clinical notes), to confirm whether notices met the 30-day posting requirement, and to consider extending the retroactive request window beyond one business day. Sherry (DMS staff) said the add-on is the coded item for which prior authorization is required, not the base psychotherapy hour, and that states can define HCPCS code use differently. DMS and WellCare agreed to follow up with written clarifications and to put the issue on the BHTAC agenda in May for continued discussion.
Next steps: DMS will assemble examples of other after-the-fact PAs and clarify notice timing; WellCare will revisit how it notifies providers and accept feedback on the one-business-day requirement. The TAC planned to draft a recommendation if changes were not satisfactory.
