Approved Carelon authorizations
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This document explains how WellSense will handle existing Carelon behavioral health authorizations during the insourcing of behavioral health services and how out-of-network care will be managed; it affects providers treating WellSense members and WellSense prior-authorization processes.
No material clinical or coverage changes in this revision.
Coverage During Behavioral Health Insourcing
Coverage during transition
Coverage and authorization stance during behavioral health insourcing
ALL of the following
Existing Carelon authorizations
- WellSense will load and honor all authorizations previously approved by Carelon through June 30, 2026, or the end of the authorization, whichever is later.
New services on/after insourcing effective date
- All new services beginning on or after the effective date of behavioral health insourcing (Dec. 1, 2025 for New Hampshire Medicaid; Jan. 1, 2026 for all other products) that require prior authorization must be submitted to WellSense for approval.
- Services approved by Carelon do not require resubmission unless extending dates of service; you do not need to submit new prior authorization requests for services already approved by Carelon.
Inpatient admissions at transition
- For members who remain admitted to an inpatient level of care at the time of transition, Carelon will manage the admission through discharge.
- For members admitted after the transition, WellSense staff will manage the inpatient admission.
Out-of-network established care through transition
- WellSense will continue to cover established behavioral health services initiated for members, including services provided by out-of-network providers, and will authorize those established services through June 30, 2026.
- Out-of-network providers who have been providing care to a WellSense member may continue seeing that member through June 30, 2026.
Out-of-network requirements after transition
- On or after July 1, 2026, an out-of-network authorization will be required for providers not contracted with WellSense; medical necessity review is required prior to approval.
- If a new member is receiving care from an out-of-network provider, that member is expected to transition to a WellSense in‑network provider prior to or by June 30, 2026.
ALL of the following
Provider contacts
- Out-of-network providers interested in joining WellSense's behavioral health network should contact bhproviders@wellsense.org.
- For out-of-network authorization inquiries, contact the WellSense Provider Service team at provider.info@wellsense.org.
Provider Actions and Authorization Handling
Handling of existing and new prior authorizations
WellSense will load and honor all authorizations previously approved by Carelon through June 30, 2026, or the end of the authorization, whichever is later. New services that begin on or after the behavioral health insourcing effective dates (Dec. 1, 2025 for NH Medicaid; Jan. 1, 2026 for all other products) that require prior authorization must be submitted to WellSense. Existing Carelon approvals do not require resubmission unless you are extending the dates of service. For members admitted to inpatient care at the time of transition, Carelon will manage through discharge; admissions after the transition will be managed by WellSense.
- We will load all authorizations approved by Carelon and honor them through June 30, 2026, or the end of the authorization, whichever is later.
- New prior authorization requests for services beginning on or after the insourcing effective dates must be submitted to WellSense.
- Do not resubmit Carelon-approved authorizations unless extending dates of service.
- Carelon will manage inpatient admissions that are ongoing at transition; WellSense will manage admissions after transition.
Out-of-network authorization requirement after transition
Out-of-network authorizations will be required on or after July 1, 2026 for providers not contracted with WellSense; medical necessity review is required prior to approval. Established out-of-network behavioral health services initiated for members will continue to be authorized through June 30, 2026.
- Established behavioral health services by out-of-network providers are authorized through June 30, 2026.
- On or after July 1, 2026, out-of-network authorization is required for non-contracted providers (applies to current and future patients).
- Medical necessity review is required before approval of out-of-network authorizations.
Provider contacts for network participation and authorization
Out-of-network providers interested in joining the WellSense behavioral health network should contact bhproviders@wellsense.org. For out-of-network authorization inquiries, contact the WellSense Provider Service team at provider.info@wellsense.org.
- To request network participation: bhproviders@wellsense.org
- For out-of-network authorization inquiries: provider.info@wellsense.org
Continuity of Care (COC)
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.