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A coverage determination (exception) is a decision about whether a drug prescribed for you will be covered by us and the amount you'll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

Asking your health plan for a benefit or for them to cover a service is called an Organization Determination request. It may also be called a Prior Authorization request.

Providers must use the WellCare payer id 14163 if choosing to use Connect Center free DDE or batch upload services. WellCare encourages electronic (EDI) claim submissions. However, WellCare also accepts paper CMS-1500 and UB-04 claim forms.

A coverage decision is a decision we make about your benefits, coverage, or the amount we'll pay for your medical services or medicine. This decision is also called an organization determination when it is about a Part C medical benefit.

LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC's jurisdiction (region) in ance with section 1862(a)(1)(A) of the Social Security Act. MACs are Medicare contractors that develop LCDs and process Medicare claims.

How to Request a Coverage Determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a standard or expedited coverage determination by filing a request with the plan sponsor. Standard or expedited requests for benefits may be made verbally or in writing.

How to Request a Coverage Determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a standard or expedited coverage determination by filing a request with the plan sponsor. Standard or expedited requests for benefits may be made verbally or in writing.