Provider Bulletins

Effective August 17, 2026, Pre- and Post-Decision Peer-to-Peer (P2P) discussions will no longer result in reconsideration of inpatient and post-acute care authorization determinations. Any reconsideration of an adverse coverage determination will instead be managed exclusively through the formal appeals process.

The Wellcare Model of Care includes a standard provision stating that “provider peer-to-peer requests are permitted for disagreement with UM clinical decision making.” This language does not supersede Medicare UM or appeal requirements; any P2P process is limited to clarification of clinical rationale rather than decision-making or reconsideration of the determination.

This operational change to the utilization management (UM) process is effective for all Wellcare health plans, including Medicare Advantage and D-SNP plans in all markets.

All coverage determinations will continue to be made in accordance with applicable Medicare coverage criteria and regulatory requirements, including applicable provisions of the Code of Federal Regulations (CFR) governing Medicare Advantage Organization Determinations, including:

• CFR provisions for Organization Determinations: 42 CFR 422.566, 42 CFR 422.101
• CFR provisions for Appeals: 42 CFR 422.578, 42 CFR 422.582, 42 CFR 422.584
• CFR Provisions for Medicare Advantage Dual-Special Needs Plans designated as an Applicable Integrated Plan: 42 CFR 422.629-422.634.

Providers that disagree with an authorization determination should follow the formal appeals process outlined in the adverse determination notification letter. Providers and members retain the right to request reconsideration and submit additional clinical information as part of the appeals process.

Contact your Health Plan Representative for questions regarding this change.

Wellcare is committed to sharing CMS-provided guidance with our provider partners on the recently launched Medicare GLP-1 Bridge program.

Note: Medicare GLP-1 Bridge is a demonstration program operated by Medicare. Providers are required to submit prior authorization requests for the Bridge program directly to Medicare after assessing patient eligibility and a prescription is sent to their pharmacy. 

Providers are strongly encouraged to view resources provided by CMS, including the Prescriber Fact Sheet, for the latest program information, including:

• Eligibility criteria for Medicare Part D beneficiaries.
• Where, when and how to submit prescriptions and prior authorization requests.
• Eligible medications for the short-term demonstration program.
• Expected costs for Part D beneficiaries, including those receiving a low-income subsidy (LIS).

For additional program information and additional resources, visit CMS.gov. Additional guidance developed by CMS and recommended next steps are provided as a benefit to our provider partners continues below.

CMS Launches Medicare GLP-1 Bridge Program 

The Centers for Medicaid and Medicare Services (CMS) launched a new program called Medicare GLP-1 Bridge on July 1, 2026, and it is expected to run through Dec. 31, 2027.

 This short-term demonstration program for beneficiaries enrolled in a Medicare Drug Coverage Plan (Part D) is intended to expand access to certain GLP-1 medications for weight management for Part D beneficiaries not eligible to receive a GLP-1 drug through their Part D plan and do not have type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease. 

The Medicare GLP-1 Bridge uses a CMS-established central processor that is not affiliated with Part D health plans. This processor should be used by providers for allprior authorization, claims adjudication, and pharmacy reimbursement.

Note: Wellcare Medicare Part D plans are unable to accept, process, or support any prior authorization requests or reimbursements affiliated with the GLP-1 Bridge Program.

Which Medicationsare Eligible for the GLP-1 Bridge Program?

 As of July 1, 2026, the Medicare GLP‑1 Bridge currently includes Wegovy® (all formulations), Foundayo® (all formulations), and Zepbound® (KwikPen only).

Visit CMS.gov for the latest information on eligible medications for the program.

Who is eligible to participate in the GLP-1 Bridge Program?

Medicare beneficiaries may qualify for the demonstration program if they:

1. Are enrolled in Medicare Part D coverage.
2. Are prescribed an eligible GLP‑1 for weight management only, not another approved Part D indication.
3. Meet the Medicare GLP-1 Bridge clinical criteria.

  Examples of the clinical thresholds include individuals with a Body Mass Index (BMI) that is greater than or equal to:

• 35%
• 30% with identified comorbidities
• 27% with qualifying health risks

Medicare beneficiaries receiving GLP‑1 drugs through Part D for other medically accepted indications are ineligible for the Bridge program. CMS has developed a dedicated resource for more information on clinical thresholds and additional Bridge program details at the following link: Medicare GLP-1 Bridge Prescriber Information.

What is theexpected cost for eligible Part D beneficiaries?

Eligible individuals, including those who receive a low-income subsidy (LIS), typically pay a $50 copay per fill. Costs associated with the GLP-1 Bridge Program do not count toward Part D out-of-pocket (TrOOP) or benefit phases. 

What is the appropriate process for submitting prior authorization requests and/or claims for the GLP-1 Bridge Program?

Pharmacies are required to submit all prescriptions through the Medicare GLP-1 Bridge central processor. For all process and program information, providers, prescribers andpharmacies visit CMS.gov.

Providers should send prescriptions for patients who may be eligible to their pharmacy using the instructions found in the CMS issued resources.

Reminder: Wellcare Medicare Part D plans are unable to accept, process, or support any prior authorization requests, claims submissions, or reimbursements affiliated with the GLP-1 Bridge Program.

When is it appropriate to submit a prior authorization request to a Part D health plan for a GLP-1 medication?

Providers should submit the appropriate information, including prior authorization requests, to a Part D plan when a beneficiary is a candidate for a GLP-1medication, and one or more of the following are true:

A. They have previously been prescribed a GLP-1 medication through the Part D program.

B. They have a Part D covered indication, such as Type 2 diabetes (T2D), Obstructive Sleep Apnea (OSA), or Metabolic Dysfunction-Associated Steatohepatitis (MASH).

C. Does not meet the Medicare GLP-1 Bridge clinical criteria.

Who can I contact if I have additional questions or concerns?

Providers should visit CMS.gov to stay updated with the most relevant information on the GLP-1 Bridge Programor call 855-273- 0102 from 8 a.m. to 7 p.m. Monday through Friday.

The GLP-1 Bridge Program is operated directly by Medicare. Providers with questions about the program that contact their Wellcare Health Plan Representative may be directed to the resources provided above for additional information.

The following information and recommended action items are provided by Wellcare as a courtesy. Providers are encouraged to visit CMS.gov to confirm the requirements and processes affiliated with the GLP-1 Bridge Program.

• Identify Medicare Part D beneficiaries that may meet GLP‑1 Bridge eligibility criteria defined at CMS.gov.
• Send the prescription claim through the standard process and include an obesity diagnosis (E66) with “SEND TO BRIDGE FOR WEIGHT MANAGEMENT” in the note/annotation. This will enable the pharmacy to route the claim to the Medicare GLP-1 Bridge program, and Medicare will confirm eligibility.
• Once eligibility is confirmed, the claim will trigger a prior authorization (PA). Providers are required to wait for the pharmacy’s ePA or fax request. This process is typically completed with in 24-to-72 hours. If an ePA/fax request is not provided within 72 hours, providers may submit a PA using the CMS GLP-1 Bridge form.
• PA determinations (approval or denial) are sent to the member by mail and to providers via ePA or fax within 72 hours. Denied requests may be resubmitted to the central processor.
• Inform the member that participation in the GLP-1 Bridge Program is separate and distinct from their Part D coverage, to be used only for weight management and will include a fixed copay that is not affiliated with standard Part D processes for all other medications. 

For additional program information and additional resources, visit CMS.gov.

The Office of Management and Budget approved the updated Medicare Outpatient Observation Notice (MOON) for three years. The updated version improves readability and design and is effective through February 28,2029.

Providers may continue to use the previous MOON but must transition to the latest version by April 20, 2026.

Providers must deliver a MOON to Medicare beneficiaries (including health plan enrollees) informing them that they are outpatients receiving observation services and are not inpatients of a hospital or critical access hospital. 

For additional instructions, see Section 400, Chapter 30, of the CMS Claims Processing Manual.

Beginning March 15, 2026, pre-payment editswill be applied for new claims processed for our Wellcare D-SNPs.

Claims for D-SNP members will now be reviewed and validated prior to payment. This transition is designed to:

• Improve claim accuracy.
• Support policy compliance, and
• Streamline payment processing.

Claims submitted prior to the pre-pay edit implementation period continue to be subject to post-payment edits, where applicable.  Any claims paid incorrectly according to policy may be subject to recoupment under standard procedures.  

Provider Responsibilities and Next Steps 

We value your continued partnership and request that you review the following reminders:

• Continue submitting complete, accurate, and timely billing information, following the guidelines outlined in your provider manual. 
• Monitor our provider bulletins webpage for additional reminders or updates. If you have any questions or concerns, please reach out to your provider engagement (PE) account manager. For more information on your PE account manager, please visit reference the provider engagement manager map available on our website.  

We appreciate your partnership during this transition. Together, we ensure claims are processed accurately and compliantly.  We look forward to continuing to work together to meet state and Centers for Medicare & Medicaid Services (CMS) requirements.

We have identified an EDI claim rejection related to provider taxonomy requirements that was incorrectly applied to some incoming claims for Wellcare dual-plan members. These fields are not required for Dual-eligible claims.

The rejection affected claims received on or after January 1, 2026, for dates of service on or after January 1, 2026. We are actively working to remediate this issue, and the correction is expected to be completed by January 15, 2026.

What providers need to do

• No action is required at this time.
• Providers do not need to resubmit claims that were rejected due to this issue.

What happens next

• Once the issue is corrected, we will reprocess all claims that were inappropriately rejected.
• Providers should begin to see claim status updates showing receipt of their claims approximately one week after the correction date.

We appreciate your patience while we resolve this issue. 

As a reminder, some Iowa Wellcare members experience coverage and most have a new Wellcare member ID this year, including those who are enrolled in our DSNP plans.

Claims for services rendered on or after January 1, 2026, must be submitted using the current year member ID. Please follow the steps below to avoid rejected claims and processing delays:

• Verify eligibility to confirm the members' current coverage and member ID.
• Obtain new authorization when required for services beginning in the new year.
• Submit claims for services on or after January 1 using the new Wellcare member ID.
• Do not submit claims that span December and January for dates of service under a single claim. Claims must be split and submitted under the corresponding plan for 2025 or 2026.
• Starting on January 1, Iowa Wellcare’s new Payer ID is 68069. 

You may verify eligibility through our secure provider portal or Availity Essentials. If you have questions regarding a specific member’s eligibility or coverage, call the Provider Services number on the back of the member’s ID card.

• 2026 Set Up PaySpan Account - DSNP (PDF)

Wellcare ushers in the new year with updates to its website, payer ID, phone numbers and more.

Provider Portal and Availity Essentials Portal
As of January 1, 2026, providers should review Wellcare data in the Provider (Legacy) Portal and Availity Essentials Portal. Providers will need to select “Wellcare Iowa Total Care” from the dropdown.

Providers will continue to have access to the Wellcare Portal for data prior to January 1, 2026.

Visit our Wellcare Providers webpage to access both the Provider Portal and Availity Essentials Portal.

Wellcare Providers Webpage
New year, new look! Visit our new Wellcare website!

Payer ID
As of January 1, 2026, Wellcare’s new Payer ID is 68069.

Provider Services Phone Numbers

• Dual Specials Needs Plans (D-SNPs): 1-855-445-3577
• All other Medicare Advantage plans: 1-800-977-7522

Member ID Cards
Members will receive new ID cards with updated member ID numbers.

• Most ID numbers will begin with a “C.”
• Contact addresses and phone number vary by member’s plan (DSNP or non-DSNP).

New Pre-Authorization Tool Link
Evolent is no longer being used for Iowa Medicare. All Wellcare (Medicare) prior authorization requests for the services listed below must be submitted to Wellcare’s secure provider portal.

• Advanced/cardiac imaging
• Physical, occupational and speech therapies
• Orthopedic and spine surgeries
• Interventional pain management
• Medical oncology 
• Radiation oncology
• Cardiac surgical procedures

We encourage you to use Wellcare’s Pre-Auth Needed Tool, to verify prior authorization requirements for specific procedure codes.

For questions or concerns, contact your provider engagement account manager or call Provider Services at 1-800-977-7522 (TTY: 711), Monday – Friday 8 a.m. - 8 p.m. CT.

Thank you for your partnership in serving our members.

Medicare has extended its current telehealth flexibilities through January 30, 2026. At this time, it is unknown whether these flexibilities will be extended further. Regardless of future Medicare decisions, Wellcare Medicare plans will continue to offer expanded telehealth access through 2026 plan years. Our benefits maintain many of the same flexibilities, ensuring no change in telehealth coverage for Wellcare’s Medicare members.

Current Medicare telehealth flexibilities include: 

• Relaxed geographic restrictions
• No originating-site requirements
• Expanded list of eligible telehealth providers

Wellcare Medicare plans will continue these allowances even if Medicare ends its flexibilities:

• Members may receive telehealth services from any location—no rural or originating-site limitations.
• No restrictions on which types of providers may deliver telehealth.
• Teladoc services remain available 24/7 at $0 cost share.
• Telehealth from in-network providers applies the same cost share as an in-office visit (e.g., PCP or specialist rates). Members should refer to their EOC for full cost-share details.
• No technology requirement—audio-only telehealth is permitted for certain non-behavioral, non-mental health services.

If you have any questions, please contact your Provider Engagement Representative.

• Medicare Discontinued Drugs and Formulary Alternatives (PDF)

• Important Prior Authorization Updates: Effective April 1, 2026 (PDF)

As part of our continued commitment to supporting providers and ensuring compliance with State and CMS requirements, we are implementing important system changes aligned with the Dual Special Needs Plan (D-SNP) offering, effective January 1, 2026. 

We are working to implement Pre-Payment Edits associated with the D-SNP product. These updates will enhance claim accuracy, strengthen policy compliance, and streamline payment processing. 

Temporary Process: Post Payment Edits

While implementation work continues, Pre-Payment Edits are expected to go live in early 2026. Until that time, select claims may be subject to Post-Payment Edits rather than pre-payment validations, unless otherwise stated in your provider agreement. 
This approach allows payments to continue without disruption while maintaining oversight through post-payment review. When the edits are activated, any claims paid incorrectly according to policy may be subject to recoupment under standard procedures. 

Provider Responsibilities and Next Steps

We appreciate your partnership during this transition and ask that you please review the following reminders: 

• Providers remain responsible for submitting complete, accurate, and timely billing information to ensure correct payment. Continue to submit claims per the existing guidelines outlined in your provider manual.
• Payment Integrity teams may issue additional reminders or updates as we approach go-live.
• If you have any questions or concerns, please reach out to the Provider Relations team.

We value your continued collaboration and partnership as we implement these improvements to ensure accuracy, efficiency, and compliance with claims processing.

Effective January 1, 2026, all Wellcare (Medicare) prior authorization requests will transition from Evolent to Wellcare.

This transition is only for Wellcare (Medicare). There is no change to Iowa Total Care (Medicaid) prior authorization processes.

The following Wellcare (Medicare) services will transition from Evolent to Wellcare:

• Advanced/cardiac imaging
• Physical, occupational and speech therapies
• Orthopedic and spine surgeries
• Interventional pain management
• Cardiac surgical procedures
• Medical oncology
• Radiation oncology

Please continue submitting Wellcare (Medicare) prior authorization requests to Evolent through December 31, 2025, regardless of the service dates.

Beginning January 1, 2026, all Wellcare (Medicare) prior authorization requests for the services listed above must be submitted to Wellcare’s secure provider portal.

We encourage you to use Wellcare’s Pre-Auth Needed Tool, to verify prior authorization requirements for specific procedure codes.

You may contact Provider Services at 1-855-538-0454 until December 31, 2025.

After January 1, 2026, contact Iowa’s provider engagement account management team at providerrelations@IowaTotalCare.com.

Thank you for your partnership with Wellcare.

• Important Prior Authorization updates: Effective October 15, 2025 (PDF)

On January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will implement new prior authorization (PA) response time requirements for all providers.

• Standard prior authorization requests will be completed within 7 calendar days, with a possible extension up to 14 calendar days under certain circumstances.
• Expedited/Urgent prior authorization requests will be completed within 72 hours from time of receipt of the authorization request.

With shorter response times for supporting clinical information requests, all necessary clinical information should be submitted at the time of the authorization request.

Additional Information

• Complete clinicals include Diagnosis, History and Current Condition, Treatment Plan and Interventions, and Relevant Diagnostic Tests.
• Response times can be lessened if all information is submitted with the authorization request.
• Missing clinical information may lead to a denial due to inadequate supporting records.
• Submitting prior authorization requests via the secure Availity portal allows for faster review.

Centene clinical policies and criteria can be found at Availity. If you have any questions, please contact your provider relations representative.

June 16, 2025

Dear Provider,

The Centers for Medicare & Medicaid Services (CMS) require health plans to provide annual education and training regarding our Special Needs Plan (SNP) Model of Care to providers who treat our SNP members. This applies to our Dual Eligible Special Needs Plan (D-SNP) members, who are eligible for both Medicare and Medicaid, and our Chronic Condition Special Needs Plan (C-SNP) members.

As stated in our provider manual, all providers who treat our SNP members, regardless of network participation status, must complete Model of Care (MOC) training annually by Dec. 31. The training is designed to help you better understand our approach to the delivery of care for SNP members.

How to Access Training

The SNP MOC training is available for download and self-study here.

We appreciate the quality care you provide to our members and your support of our efforts to meet CMS regulations.

For additional information on how to work with our health plan to manage SNP members, please visit our Provider Resources page. The Provider Resources page includes links to provider manuals, Quick Reference Guides, Clinical Practice Guidelines, and more.