Intent to Deny Process

Date: 11/06/24

Wellcare Pre-Service Utilization Management is implementing an intent to deny/Peer-to-Peer pre-determination process, for Outpatient Prior-Authorizations only, effective November 12, 2024.

The Intent to Deny/Peer-to-Peer pre-determination process give practitioners the opportunity to discuss Utilization Management Pre-Service Outpatient denial decisions with a physician or other appropriate reviewer prior to the denial to decision.

The Intent to Deny/Peer-to-Peer pre-determination changes will be in effect beginning November 12, 2024:

• Prior to a Wellcare Outpatient Prior-Authorization denial, the requesting provider will be notified through fax of an impending denial with an Intent to Deny for Non-Authorization letter.
• The Intent to Deny for Non-Authorization letter will serve as a formal and final request for information. 
• The Requesting Provider can schedule a Peer-to-Peer Review within the identified business days of the letter.
• The Intent to Deny for Non-Authorization letter will identify the Prior-Authorization denial date and a formal denial letter with appeal information will be issued on that date.

The Intent to Deny for Non-Authorization should not delay appropriate medical patient care.

If you have questions, please contact Provider Relations.