Effective Date: Dates of Service on or after January 1, 2026
Wellcare of Texas has delegated certain administrative and clinical functions to Astrana Health for select Medicare Advantage members assigned to Astrana Texas Independent Practice Associations (IPAs).
This delegation impacts how providers submit authorizations, referrals, and claims for applicable members.
Affected Products and Providers
This applies to Wellcare Medicare Advantage HMO and PPO products, including Wellcare Simple and Wellcare Texas Plus.
Geographic Scope:
Delegated membership is limited to members assigned to Astrana Texas IPAs (ASTHOU and ASTBEAU), primarily serving Harris and Jefferson counties.
Delegation Summary
Effective January 1, 2026, Astrana Health assumes responsibility for the following functions for delegated members:
- Utilization management (inpatient and outpatient)
- Authorization and referral processing
- Claims processing and payment
- Care and case management
- Disease management
- Credentialing
- Network management
- Provider-facing customer service
Wellcare of Texas retains responsibility for:
- Member eligibility and covered benefits
- Appeals
- Member complaints and grievances
- Member identification cards and materials
- CMS and regulatory reporting
Provider Responsibilities
1. Member Assignment Verification
Providers must verify whether a member is assigned to an Astrana Texas IPA prior to submitting requests.
Assignment indicators may include eligibility verification through the Wellcare Secure Provider Portal. ID cards may reflect Astrana affiliation but should not be relied upon as the sole source.
Eligibility and benefits must continue to be verified through Wellcare.
2. Authorization and Referral Submission
For delegated members, all authorization and referral requests must be submitted to Astrana Health.
Submission methods:
- Preferred: Astrana Provider Portal
https://provider-portal.astranahealth.com/login - Fax (limited use):
- Routine: (945) 262-0343
- Urgent: (945) 262-0340
- Notes/Modifications: (945) 262-0344
3. Inpatient Admission Notification
Providers are required to notify Astrana Health within 24 hours of inpatient admission. Failure to provide timely notification may result in denial of services.
4. Claims Submission Requirements
Claims responsibility is determined by provider contract status and delegation of financial responsibility (DOFR). Astrana-contracted providers generally submit claims to Astrana (Payer ID NMM13). Providers contracted only with Wellcare may submit claims to Wellcare. No-wrong-door routing applies.
Timely Filing Requirement:
Claims must be submitted within 60 days of the date of service.
No-Wrong-Door Policy:
Claims submitted to the incorrect entity will be redirected to the appropriate payer for processing.
Additional Information
- Providers are not required to be contracted with Astrana Health to refer members to Astrana-participating providers.
- Authorizations are required when applicable.
- Providers may utilize either the Astrana network or the broader Wellcare network, based on member needs and preferences.
For questions regarding this delegation, including authorizations, referrals, or claims submission: PR.Houston@SuperiorHealthplan.com
