Wellcare Medicare
Welcome to the Wellcare Medicare page. The documents below have been designed to help RadMD users navigate the prior authorization process for each program Evolent is responsible for. Additional process-specific training tools and modules can be found via links on the Resources tab at the top of the screen.
MEDICARE plans: Effective 8/5/2024, peer-to-peer discussions must be performed before a final determination has been made on the request. Medicare re-opens are only allowed if the request complies with the CMS definition of a re-open. Providers will continue to have the option to submit an appeal utilizing the health plan’s process.
If you have any questions about our programs, please contact your dedicated Evolent Provider Engagement Manager.
Advanced and Cardiac Imaging Program
- Cardiac Imaging Frequently Asked Questions
- Frequently Asked Questions
- Peer-to-Peer Process
- Provider Education Presentation
- Utilization Review Matrix (AR, AZ, CT, DE, FL, GA, IL, IN, KY, LA, MI, MO, MS, NC, NJ, NY, OH, SC, TN, TX, WA)
For access to our Advanced Imaging tip sheets/checklists, click here.
For access to our Cardiac Imaging tip sheets/checklists, click here.
For access to State-specific Cardiac Imaging Program documents, click below:
Interventional Cardiology Program (CT, FL, GA, HI, IA, IL KY, LA, ME, MI, MO, MS, NC, NJ, OH, SC, TN, TX, WA)
- Scope of Service
- Utilization Review Matrix
For access to State-specific Interventional Cardiology Program documents, click below:
- Texas - Effective July 1, 2025
Interventional Pain Management Program
- Frequently Asked Questions
- Provider Education Presentation
- Utilization Review Matrix (CT, GA, IA, IL, IN, KY, KS, LA, ME, MI, MS, NC, NJ, NY, OH, PA, SC, TN, TX, VT, WA)
- Utilization Review Matrix (AR, MO)
For access to State-specific Interventional Pain Management Program documents, click below:
For access to our Interventional Pain Management tip sheets/checklists, click here.
Musculoskeletal Program
- Utilization Review Matrix (MSK - Hip, Knee and Shoulder - Medicare) (CT, FL, GA, HI, IA, IL, IN, KY, LA, NJ, NY, ME, MI, MO, MS, NC, OH, PA, SC, TN, TX, WA)
- Utilization Review Matrix (MSK - Spine Surgery - Medicare) (CT, FL, GA, HI, IA, IL, IN, KY, LA, NJ, NY, ME, MI, MO, MS, NC, OH, PA, SC, TN, TX, WA)
For access to State-specific Musculoskeletal Program documents, click below:
- Connecticut
- Georgia
- Indiana
- Iowa
- Louisiana
- Maine
- Michigan
- Mississippi
- Missouri
- New Jersey
- Ohio
- Oklahoma
- South Carolina
- Tennessee
- Texas
- Washington
For access to our Musculoskeletal tip sheets/checklists, click here.
Physical Medicine Program
For access to State-specific Physical Medicine Program documents, click below:
Update for Wellcare Connecticut, New York and Tennessee:
- Home Health Providers submitting claims utilization G-Codes for all home therapy services are excluded from the Physical Medicine Program
Update for Wellcare Kentucky, Louisiana and Connecticut:
- Effective 07/01/2022 Inpatient and Outpatient Therapy performed in a Home Health Setting is excluded from the Physical Medicine Program
For access to our Physical Medicine tip sheets/checklists, click here.
Conservative Treatment Forms
For access to our conservative treatment forms, click here.
Low Dose Chest CT History Form
Clinical Guidelines
- Clinical Guidelines
- Refer to the Utilization Review Matrix document to view specific codes managed by Evolent.