For Providers

• 2026 Wellcare Provider Manual (PDF)

• Appeals/Reconsiderations (Medical) and Grievances Guide (PDF)
• Claims, Disputes & Recovery/CCU Guide (PDF)
• Pharmacy Guide (PDF)
• Prior Authorization Guide (PDF)
• Medicare Quick Reference Guide (PDF)
• Appointment Availability Standards (PDF)
• Premier Eye Care Quick Reference Guide (PDF)

In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.

Reports:

• Wellcare CMS Final Rule 0057-F Prior Authorization Requirements: H1215 & H1395 (PDF)
• Wellcare Prior Authorization Metrics Summary: H1215 (PDF)
• Wellcare Prior Authorization Metrics Summary: H1395 (PDF)

The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.

• 2026 Alternative Covered Drugs (PDF)
• Step Therapy Part B Provider updated (PDF)

Special Supplemental Benefits for the Chronically Ill (SSBCI) can be offered to Medicare Advantage (MA) members who have one or more complex chronic conditions, are at high risk for hospitalization or adverse health outcomes and require intensive care coordination. SSBCI aims to improve overall health outcomes for the chronically ill population by addressing social needs beyond traditional medical care such as food, housing, transportation, and gaps in care. The program is designed to support individuals by offering additional services beyond standard Medicare coverage.

Members must qualify for SSBCI benefits

Members must meet all three criteria to qualify:

• The member must require intensive care management.
  • The member must have a history of frequent outpatient services or specialty care and/or, evidence of poor disease control or medication adherence and/or, social or behavioral factors impacting health outcomes. 
• The member must be at high risk for unplanned hospitalization.
  • The member must have a history of frequent hospitalizations or ED visits related to the chronic condition.
• The member must have a documented and active diagnosis for a qualifying chronic condition.
  • The chronic condition must be life threatening or significantly limit the overall health or function of the member.

How to Determine Eligibility

Auto Eligibility Process: We utilize internal and claims data in our  internal algorithm to identify members that meet the three criteria. This automatic process refreshes weekly, and links member data across time and health plans, enabling a comprehensive view of historical claims. This process includes all members enrolled in an SSBCI-eligible plan.

Manual Eligibility Process: We may not have claims data or medical records for new members early in the year. These members can go through the manual process to have a provider attest to their eligibility.

To begin the SSBCI manual eligibility process, members must schedule an in-person office visit or contact their healthcare provider to request the attestation be completed. If an office visit is required to complete the attestation, the provider will evaluate the member’s health status during the visit and determine if they meet SSBCI criteria. 

Provider Instructions for SSBCI Attestation

Providers should follow these steps to complete the attestation:

1. Visit  ssbci.rrd.com.
2. Review the eligibility criteria outlined on the site (see criteria above) and evaluate the member accordingly.
3. Submit an attestation through the website confirming the member meets SSBCI eligibility requirements.
4. Submit a claim from the office visit that includes the appropriate diagnosis codes indicating the member has one or more What Happens Next?qualifying chronic conditions listed on ssbci.rrd.com.

What Happens Next?

Once the attestation is received:

• The member will receive an approval or denial letter within 10 business days.
• If approved, the letter will include details about the specific SSBCI benefits available and instructions on how to access them.

HEDIS Resources:

• 2026 HEDIS Guide
• Wellcare Annual Care for Older Adults Form (COA) (PDF)
• HEDIS^® Measurement Year 2022 At-A-Glance Behavioral Health Measures (PDF)
• CAHPS Wellcare Provider Patient Experience
• 2024 Provider Guide
• HOS Tips for Improving Patient Experience and Quality of Life
• English CAHPS Office Poster

• CAHPS Resource Guide (PDF)
• Wellcare Provider-Patient Experience (PDF)
• Tips for Improving Patient Experience & Quality of Life (PDF)

• Anti-Kickback Training (PDF)
• Anti-Kickback Attestation (PDF)
• Fraud, Waste and Abuse Training: Medicaid and Medicare (PDF)
• Fraud, Waste and Abuse Referral Form (PDF)
• Provider Model of Care Training (PDF)

• Medicare Inpatient Authorization (PDF)
• Medicare Outpatient Authorization (PDF)

• Provider Medicine Request Checklist (PDF)
• Prior Authorization Information (PDF)
• Wellcare Health Plans Utilization Review Matrix 2021 (PDF)
• Provider Outreach and Clinical Engagement Strategy for Wellcare (PDF)

FAQ's

• Evolent FAQ's For Wellcare Providers (PDF)
• Evolent FAQ's Wellcare Prior Authorization Physical Medicine (PDF)

Cardiac

• Cardiac Checklist (PDF)
• Cardiac Imaging Frequently Asked Questions (PDF)
• Cardiac Solution Program Tip Sheet MPI vs. SE (PDF)

Quick Reference Guides

• Wellcare Physical Medicine Prior Authorization Quick Reference Guide for Providers (PDF)
• Wellcare Quick Reference Guide for Rendering Providers (PDF)
• Wellcare Quick Reference Guide for Ordering Providers (PDF)