Exciting News: More Flexibility for External Specialist Services!

From: WelbeHealth
To: Health Plan Providers
Type: Informational
Subject: Effectuation of Care (EOC) – Specialist Flexibility
Business: PACE
State(s): PACE – California

Dear Valued Provider,
WelbeHealth is excited to share an update that makes working with us easier while ensuring timely access to care for our participants.

What’s Changing?
Specialists now have the clinical oversight to provide additional services during an existing appointment. These services may be performed or scheduled at the same or a follow-up visit if not on the Prior Authorization (PA) List.

Specialist Definition: A specialist is a licensed healthcare professional with advanced training in a specific area of medicine or behavioral health who provides evaluation, diagnosis, or treatment services outside the participant’s primary care setting.

Please Note – Exceptions:
• Laboratory Services (including blood draws, urine testing, pathology, etc.) – excluded from this process and must continue to follow existing workflows.
• Dental specialists – Managed separately under the Dental process.

Key Reminders
• Initial Orders: All services must start with a WelbeHealth order; specialists cannot initiate the first order.
• Prior Authorization:
o Services not on the PA List do not require PA when delivered during external specialist visits.
o Services on the PA List must follow our standard PA process:
•  PA List: welbehealth.com/partners
• Submit requests via QuickCap Provider Portal (preferred) or fax the Authorization Request Form to (209) 729-5854.

• Medical Records: Case notes must be submitted within five (5) days of the Date of Service.

Why This Matters?
• Less administrative burden
• Expanded access to services
• Stronger collaboration between providers and WelbeHealth

WelbeHealth Provider Partnership Department

___________________________________________________________________________________

If you have any questions, please contact your Provider Partnership Representative, or email the Provider
Partnership team at providers@welbehealth.com . You may also visit welbehealth.com/partners. for online access to
this document and all other WelbeHealth Provider Alerts