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
If prior authorization is required, submit a prior authorization request using the instructions below. Beginning March 1, 2024, all providers will be required to submit outpatient and inpatient authorization requests for procedures and services*, confirm authorization numbers and check the status of an authorization using the WellSense provider portal. Register for access here.
| Type | Instructions |
|---|---|
|
Medical |
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.
*For New Hampshire providers, the primary method for submitting authorization requests will be the WellSense provider portal. For those providers who continue to submit prior authorization requests via fax, these requests are expected to experience longer processing times. |
| Gene therapy drugs |
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.
*For New Hampshire providers, the primary method for submitting authorization requests will be the WellSense provider portal. For those providers who continue to submit prior authorization requests via fax, these requests are expected to experience longer processing times. |
| Medical benefit (provider-administered) drugs |
Clarity New Hampshire and New Hampshire Medicare Advantage (HMO & PPO)
Clarity Massachusetts, Massachusetts Medicaid (MassHealth) and New Hampshire Medicaid |
| Pharmacy benefit drugs |
Prior authorizations for medications dispensed at a pharmacy |
| Behavioral health | |
| Durable medical equipment |
Check this document to confirm which provider types are managed by Northwood, Inc and which are managed by WellSense. |
| Radiology services |
|
| Genetic testing |
|
| Musculoskeletal services (joint surgeries, spine surgeries, and interventional pain management treatments) |
|
| Vision services | |
| Dental services |
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.
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