WellCare Medicare
Welcome to the WellCare Medicare Health Plan page. Here you can download policies and procedures specific to both ordering and rendering providers. These include quick reference guides and information designed to assist you in using RadMD to request and check the status of prior authorizations.
If you have any questions about our programs, please contact your dedicated NIA Provider Relations Manager:
- Alabama (4/1/21): Debbie Patterson
- Arizona (3/1/21): Lori Fink
- Arkansas (4/1/21): Leta Genasci
- California (1/1/22): Debbie Patterson
- Connecticut (4/1/21): Charmaine Everett
- Florida (4/1/21): Andrew Dietz
- Georgia (4/1/21): Debbie Patterson
- Illinois (4/1/21): Leta Genasci
- Indiana (4/1/21): Andrew Dietz
- Kentucky (4/1/21): Andrew Dietz
- Louisiana (4/1/21): Gina Braswell
- Michigan (4/1/21): Meghan Murphy
- Maine (4/1/21): Meghan Murphy
- Massachusetts (1/1/22): Meghan Murphy
- Michigan (4/1/21): Meghan Murphy
- Missouri (4/1/21): Gina Braswell
- Mississippi (4/1/21): Priscilla Singleton
- Nebraska (1/1/22): Andrew Dietz
- New Hampshire (4/1/21): Seth Cohen
- New Jersey (4/1/21): Seth Cohen
- New York (4/1/21): Seth Cohen
- North Carolina (7/1/21): Priscilla Singleton
- Ohio (4/1/21): Meghan Murphy
- Oklahoma (1/1/22): Gina Braswell
- Rhode Island (1/1/21): Meghan Murphy
- South Carolina (4/1/21): Priscilla Singleton
- Tennessee (4/1/21): Debbie Patterson
- Texas (4/1/21): Gina Braswell
- Vermont (1/1/21): Meghan Murphy
- Washington (4/1/21): Debbie Patterson
Effective 1/20/2023, National Imaging Associates, Inc. is now a subsidiary of Evolent Health. Evolent Health and its affiliates and subsidiaries collectively referred to as “Evolent.”
Advanced Imaging Program
- Provider Training
- Quick Reference Guide for Ordering Providers
- Quick Reference Guide for Rendering Providers
- Frequently Asked Questions
- Utilization Review Matrix-2023 - effective 4/1/23
- Prior Authorization Checklist
- Cardiac Frequently Asked Questions
- Peer-to-Peer Process
For access to our Advanced Imaging Program tip sheets/checklists, click here.
For access to our Cardiac Program tip sheets/checklists, click here.
Physical Medicine Program
UPDATE for Wellcare New York, Wellcare Tennessee, and Wellcare Connecticut:
Home Health Providers submitting claims utilizing G-Codes for all home therapy services are excluded from this program.
- Wellcare Medicare CT - Physical Medicine Provider Education Presentation
- Wellcare Medicare CT - Physical Medicine Quick Reference Guide
- Wellcare Medicare CT - Physical Medicine Frequently Asked Questions
- Wellcare Medicare NY - Physical Medicine Provider Education Presentation
- Wellcare Medicare NY - Physical Medicine Quick Reference Guide
- Wellcare Medicare NY - Physical Medicine Frequently Asked Questions
- Wellcare Medicare TN - Physical Medicine Provider Education Presentation
- Wellcare Medicare TN - Physical Medicine Quick Reference Guide
- Wellcare Medicare TN - Physical Medicine Frequently Asked Questions
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
- Physical Medicine Tip Sheet and Checklist
- Physical Medicine Provider Training
- Physical Medicine Quick Refence Guide
- Physical Medicine Frequently Asked Questions
Musculoskeletal Management (MSK) Program
- Wellcare Medicare NJ - Provider Education Presentation
- Wellcare Medicare NJ - Frequently Asked Questions
- Wellcare Medicare NJ - Quick Reference Guide
- Wellcare Medicare NJ - Joint Surgery Utilization Review Matrix-2023
- Wellcare Medicare NJ - Spine Surgery Utilization Review Matrix-2023
For access to our Surgery Program tip sheets/checklists, click here.
IPM Program
- IPM Utilization Review Matrix-2023
- IPM Provider Training
- IPM Frequently Asked Questions
- IPM Quick Reference Guide
- Wellcare Medicare NJ - IPM Provider Training
- Wellcare Medicare NJ - IPM Frequently Asked Questions
- Wellcare Medicare NJ - IPM Quick Reference Guide
- Wellcare Medicare NJ - IPM Utilization Review Matrix-2023
- Wellcare Medicare GA - IPM Provider Training - Effective 7/1/2023
- Wellcare Medicare GA - IPM Frequently Asked Questions - Effective 7/1/2023
- Wellcare Medicare GA - IPM Quick Reference Guide - Effective 7/1/2023
- Wellcare Medicare GA - IPM Utilization Review Matrix - Effective 7/1/2023
For access to our IPM Program tip sheets/checklists, click here.
Conservative Treatment Forms
For access to our conservative treatment forms, click here.
Low Dose Chest CT History Form
RadMD Documents
RadMD is a user-friendly, real-time tool offered by NIA that provides ordering and rendering providers with instant access to prior authorization requests for specialty procedures. Whether submitting exam requests or checking the status of prior authorization requests, providers will find RadMD to be an efficient, easy-to-navigate resource.
Search for resources by program:
Recorded General Trainings
We have a series of training videos that discuss the components of requesting a prior authorization request. Click here to access these videos.
Recorded RadMD Demos
Need additional help using RadMD? Click here to access a series of RadMD demos that demonstrate how to properly submit a prior authorization request.
2013 Jimmo vs Sebelius Settlement Agreement
Click here for information about the 2013 Jimmo v. Sebelius settlement involving skilled nursing and skilled therapy services.
Clinical Guidelines
- Clinical Guidelines
- Refer to the Utilization Review Matrix document to view specific codes managed by NIA
- Click here to view NIA’s Physical Medicine guidelines
Clinical Training Modules
We have a series of clinical training modules that will help you avoid delays and ensure that you have the right information before submitting your prior authorization request. Click here to access them.
Update on COVID-19
Click here to view our recommendations on the use of CT to detect Coronavirus (COVID-19).