Alignment of Utilization Management Edits for Outpatient Hospital Drugs

WellCare of North Carolina is providing advance notice to its provider network of an upcoming update to utilization management (UM) requirements applicable to drugs billed under the Outpatient Hospital benefit.

Overview

In alignment with guidance issued by the North Carolina Department of Health and Human Services (NCDHHS) regarding utilization management and Food and Drug Administration (FDA) labeling, WellCare of North Carolina intends to apply utilization management edits—based on FDA-approved indications and usage—to drugs billed under the Outpatient Hospital benefit.

These utilization management edits will be consistent with those currently in place under the Physician Administered Drug Program (PADP) and are intended to promote uniformity, clinical appropriateness, and regulatory compliance across sites of care.

What Is Changing

• Utilization management edits based on FDA-approved indications and usage will apply to Outpatient Hospital claims.
• These edits will mirror those currently applied under the Physician Administered Drug Program (PADP).
• The change applies only to utilization management alignment and does not introduce new clinical criteria beyond those already established under PADP.