Transition of Care (TOC) Authorization Information
June 18, 2021
WellCare of North Carolina Medicaid providers are not required to obtain an authorization for professional services (see table below) for the 90-day post-go live period from 7/1/2021 through 9/28/2021. Authorizations will be required for claims processing for services that require an authorization for all dates of service 9/29/2021 and thereafter. Please review our Authorization Look-Up Tool for authorization requirements and prepare to submit authorizations on or about 9/1/2021 for those services that require authorization after 9/28/2021.
NC Go Live - TOC Authorization Process
In effect until 9/28/21. Services on or after 9/29/21 WILL require authorizations.
See NC Authorization Lookup Tool.
Review category | Review type | Notification Required | Auth Required | Auth Required |
|
|
| In Network | Out of Network |
Pre-certification |
|
|
|
|
| Inpatient (medical) – elective | N | Y | Y |
| Inpatient (medical) – emergency | N | Y | Y |
| Inpatient (BH) | N | Y | Y |
| Inpatient (SUD) | N | Y | Y |
| Inpatient (surgery) – elective | N | Y | Y |
| Inpatient (surgery) - emergency | N | Y | Y |
| Post-acute (SNF, LTACH) | N | Y | Y |
| Comprehensive inpatient rehabilitation facilities (POS 61) | N | Y | Y |
Concurrent review |
|
|
|
|
| Inpatient (medical) – elective | N/A | Y | Y |
| Inpatient (medical) – emergency | N/A | Y | Y |
| Inpatient (BH) | N/A | Y | Y |
| Inpatient (SUD)
| N/A | Y | Y |
| Inpatient (surgery) – elective | N/A | Y | Y |
| Inpatient (surgery) - emergency | N/A | Y | Y |
| Post-acute (SNF, LTACH) | N/A | Y | Y |
Medical Prior Authorization |
|
|
|
|
Vendor |
|
|
|
|
| Imaging | N | N | N |
| Cardiac services | N | N | N |
| Radiation oncology | N | N | N |
| Surgical services | N | N | N |
| PT/OT/ST | N | N | N |
| Pain procedures | N | N | N |
| Sleep studies | N | N | N |
| Lab (genetic testing/complex lab) | N | N | N |
|
|
|
|
|
Non-Vendor |
|
|
|
|
| Outpatient Surgical procedures | N | N | N |
| Office-based procedures | N | N | N |
| DME (See WellCare of NC QRG for DME items that require prior authorization) | N | Y | Y |
| Home Health (nursing) | N | Y | Y |
| Lab | N | N | N |
| Transplant | N | N | N |
|
|
|
|
|
Behavioral Health Prior Authorization |
|
|
|
|
| BH outpatient services (Medication management, psychiatric and biopsychosocial assessment, individual, group, and family therapies, psychotherapy for crisis, and psychological testing) | N | N | N |
| Diagnostic Assessment | N | N | N |
| Peer Support Services | Y | N | N |
| Mobile Crisis | Y | N | N |
| Professional treatment services in facility-based crisis program | Y | N | N |
| Outpatient Opioid Treatment (billed using H0020) | Y | N | N |
| Ambulatory Detoxification | Y | N | N |
| Non-Hospital Medical Detoxification | Y | N | N |
| Other home-based services (PCS, PDN, BH) | N | Y | Y |
| Medically Supervised or ADATC Detoxification Crisis Stabilization | Y | Y | Y |
| Research-based Intensive Behavioral Health Treatment for Autism Spectrum Disorder | Y | Y | Y |
| Facility-based Crisis Services for Children and Adolescents | Y | Y | Y |
| Partial Hospitalization | Y | Y | Y |
| Psychological services in health departments and school-based health centers sponsored by health departments | Y | Y | Y
|