Centene / WellCare

Centene / WellCare

Centene Corporation

Provider guide for Centene Corporation and its subsidiaries including WellCare, Ambetter, and state Medicaid managed care plans.

Quick Reference

Payer Type

Medicaid MCO

Parent Company

Centene Corporation

Headquarters

St. Louis, MO

Provider Portal

Open Portal

Portal Guide

View Guide →

Credentialing

CAQH ProView

Timeline

90-120 days (varies by state subsidiary)

Coverage

1 states

Last Verified

Apr 19, 2026

Published

Mar 15, 2026

Reading Time

9 min

Covered Levels of Care

• Detoxification
• Residential Treatment (state-dependent)
• Partial Hospitalization (PHP)
• Intensive Outpatient (IOP)
• Outpatient Treatment
• Crisis Stabilization
• Medication-Assisted Treatment (MAT)

Medical Necessity Criteria

• State-Specific Medicaid Guidelines
• ASAM Criteria (for SUD level of care placement in most states)

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Overview

Centene Corporation is the largest Medicaid managed care company in the United States, headquartered in St. Louis, Missouri. The company serves approximately 28 million members as of 2025 across government-sponsored and commercial healthcare programs, with its core business concentrated in Medicaid managed care. Centene’s 2020 acquisition of WellCare Health Plans significantly expanded its footprint, creating a combined entity that operates Medicaid managed care plans in 30 states.

Centene does not operate under a single national brand. Instead, the company runs dozens of state-specific subsidiary health plans, each operating under its own name, branding, provider network, and operational processes. WellCare remains a prominent subsidiary brand in several states — including for Medicare Advantage (formerly marketed as Allwell, which Centene retired and consolidated under the WellCare brand in 2021–2022) — while other subsidiaries include Ambetter (ACA marketplace plans), Sunshine Health (Florida), Peach State Health Plan (Georgia), Buckeye Health Plan (Ohio), Home State Health (Missouri), Magnolia Health (Mississippi), and many others.

For behavioral health treatment providers, Centene and its subsidiaries represent one of the largest Medicaid payer relationships in the country. Because Medicaid is the single largest payer for behavioral health services in the United States, understanding how to work effectively with Centene’s various plans is essential for any treatment facility that serves Medicaid populations. The challenge lies in navigating the subsidiary structure, since each state plan operates with distinct authorization workflows, credentialing processes, covered benefit designs, and reimbursement structures dictated by that state’s Medicaid contract.

Behavioral Health Coverage

Centene’s behavioral health coverage is defined by each state’s Medicaid program and the specific contract between the state and the Centene subsidiary operating in that market. This means that covered services, levels of care, benefit limitations, and cost-sharing requirements vary significantly from one Centene plan to another. What is covered under Sunshine Health in Florida may differ substantially from what Buckeye covers in Ohio.

Across most Centene state plans, covered behavioral health services generally include outpatient therapy, intensive outpatient programs, partial hospitalization, crisis stabilization services, and medication-assisted treatment (MAT) for opioid use disorder. Residential treatment coverage depends heavily on the state. Some states cover residential SUD treatment through their Medicaid program, while others restrict residential coverage due to the Institution for Mental Diseases (IMD) exclusion or limit it to facilities with 16 or fewer beds. States with 1115 waivers may have expanded residential SUD coverage.

Medical necessity criteria for behavioral health services under Centene plans generally follow the state Medicaid agency’s established guidelines. For substance use disorder treatment, most Centene state subsidiaries reference the ASAM Criteria for level of care placement, though the specific application and interpretation may vary by state. Some states have adopted standardized medical necessity criteria that all Medicaid MCOs must follow, while others allow plans more discretion in clinical review processes.

Credentialing and Provider Enrollment

Centene subsidiaries primarily use CAQH ProView as the source for credentialing data, though the credentialing process must be initiated separately with each state subsidiary where you want to participate in-network. A current, fully attested CAQH ProView profile is the foundation of the credentialing process across all Centene plans.

To begin credentialing, identify the specific Centene subsidiary operating in your state. Visit centene.com for a directory of subsidiaries by state, or contact Centene’s corporate provider services for routing assistance. Each subsidiary has its own provider enrollment department that manages network applications, credentialing timelines, and contract negotiations. Some subsidiaries accept applications through online provider portals, while others require direct contact with their enrollment team.

The credentialing timeline for Centene subsidiaries typically ranges from approximately 90 to 120 days, though this varies by state and can extend longer if additional documentation is required or if the state Medicaid agency requires a separate enrollment step. Many states require behavioral health providers to be enrolled with the state Medicaid agency as a prerequisite to contracting with Medicaid MCOs like Centene. Verify your state’s requirements and complete state-level enrollment before or concurrent with your Centene subsidiary application.

Facility credentialing requires submission of current state behavioral health licenses, accreditation certificates, organizational NPI, facility liability insurance, and any state-specific certifications required for the levels of care you provide. Some Centene subsidiaries conduct site visits as part of the credentialing process, particularly for residential treatment facilities. Recredentialing cycles are generally every three years, typically aligned with NCQA standards.

Verification of Benefits (VOB)

Verifying benefits for Centene subsidiary members requires identifying the correct subsidiary plan and using that plan’s specific verification tools. Because each subsidiary operates its own systems, there is no single Centene-wide VOB process. The member’s insurance card will indicate the specific subsidiary plan name (WellCare, Sunshine Health, Buckeye, etc.) and plan-specific contact information.

Most Centene subsidiaries support electronic eligibility verification through standard HIPAA 270/271 transactions via clearinghouses. Some subsidiaries also offer eligibility lookup through their provider portals. These electronic methods typically return basic eligibility status, plan identification, and primary care provider assignment. For detailed behavioral health benefit information, including covered levels of care, authorization requirements, and any plan-specific limitations, providers often need to call the subsidiary’s provider services line.

When verifying benefits for Medicaid members, keep in mind that Medicaid coverage is effective on specific dates and can change monthly based on the member’s eligibility redetermination. Always verify eligibility on or close to the date of service. Also verify whether behavioral health services are carved out to a separate behavioral health organization or managed directly by the Centene subsidiary, as some states use carve-out arrangements for behavioral health.

Document all VOB interactions thoroughly, including the date of verification, representative name, reference number, plan name, covered services confirmed, and any authorization requirements communicated. For Medicaid members, also verify whether the member has a share of cost, spend-down requirement, or third-party liability that could affect claims payment.

Prior Authorization Requirements

Prior authorization requirements for behavioral health services under Centene subsidiary plans are dictated by the state Medicaid contract and vary by subsidiary. Most Centene plans require prior authorization for residential treatment, medically managed detoxification, and partial hospitalization. Some state plans also require authorization for intensive outpatient services or extended outpatient treatment beyond a certain number of visits.

Authorization submission methods vary by subsidiary. Many Centene plans accept authorization requests through their provider portals, while others require phone or fax submissions. Some subsidiaries have implemented electronic prior authorization through platforms like Availity or their own proprietary systems. Check with the specific subsidiary for their preferred submission method and any required forms.

When submitting authorization requests, provide comprehensive clinical documentation that addresses the applicable medical necessity criteria for the state. For SUD treatment, this typically means documenting the member’s status across the ASAM Criteria dimensions, including acute intoxication or withdrawal risk, biomedical conditions, emotional or behavioral conditions, treatment acceptance, relapse potential, and recovery environment. Include relevant treatment history, current functional status, and a clear treatment plan with measurable goals.

Concurrent reviews are standard for residential and inpatient services across Centene subsidiaries. The frequency of concurrent review varies by state and level of care but is typically approximately every 5 to 10 days for residential treatment, though intervals can vary. Ensure your clinical team is documenting treatment progress, response to interventions, and updated discharge planning between reviews. When a concurrent review results in a denial for continued stay, the subsidiary will issue a denial notice with appeal rights. Request a peer-to-peer review promptly if you disagree with the determination.

Claims and Billing

Claims submission requirements are specific to each Centene subsidiary and are governed by the provider agreement and state Medicaid billing guidelines. Most Centene plans accept electronic claims through standard EDI 837 transactions submitted via clearinghouses. Some subsidiaries also accept claims through their provider portals. Institutional claims use the UB-04/837I format, and professional claims use the CMS-1500/837P format.

Billing codes, reimbursement rates, and covered service definitions follow the state Medicaid fee schedule and the specific contract between the subsidiary and the state Medicaid agency. Ensure you are using the correct state-specific billing codes and modifiers, as these can vary between states and between Medicaid and commercial products. Some Centene subsidiaries provide billing guides or code reference sheets through their provider portals.

Timely filing deadlines for Centene Medicaid plans are typically set by state Medicaid regulations and generally range from approximately 90 to 365 days from the date of service, depending on the state. Your provider agreement may specify the applicable deadline. Claims filed after the timely filing deadline will be denied, and appeal options for late filing are extremely limited under Medicaid rules.

Common denial reasons for behavioral health claims include missing or expired prior authorization, member not eligible on the date of service, incorrect billing codes or modifiers, duplicate claims, and services not covered under the member’s specific plan. For Medicaid claims, also watch for denials related to third-party liability (TPL), where Medicaid is the payer of last resort and requires other insurance to be billed first. Review each denial carefully and resubmit corrected claims or file appeals within the timeframes specified by the subsidiary.

Key Contact Information

Major Centene Subsidiaries by State (partial list):

• Provider Portal: centene.com healthcare providers page ↗ (routes to subsidiary-specific portals)
• Subsidiary Directory: Visit centene.com to identify the correct plan name for your state
• Credentialing: CAQH ProView for data source; contact individual subsidiary provider enrollment departments to initiate
• Prior Authorization: Contact the member’s specific Centene subsidiary — authorization phone numbers and portals are listed on the member’s insurance card and the subsidiary provider portal
• VOB: Use subsidiary-specific provider portals or call the subsidiary’s provider services line (listed on member’s card)
• Claims Submission: Electronic 837 through clearinghouses or subsidiary provider portals
• State Medicaid Enrollment: Complete state-level Medicaid provider enrollment as a prerequisite in most states

• Florida: Sunshine Health, WellCare
• Georgia: Peach State Health Plan, WellCare
• Illinois: Meridian Health Plan
• Missouri: Home State Health
• Mississippi: Magnolia Health
• Ohio: Buckeye Health Plan
• Texas: Superior HealthPlan
• Washington: Coordinated Care
• Marketplace (multi-state): Ambetter

Frequently Asked Questions

Centene operates through different subsidiary brands in each state. Common subsidiaries include WellCare, Ambetter (marketplace plans), Sunshine Health (Florida), Peach State Health Plan (Georgia), Buckeye Health Plan (Ohio), Home State Health (Missouri), and many others. Visit centene.com and navigate to the state-specific subsidiary to find the correct plan name, provider portal, and contact information for your region.

Centene operates through dozens of state-specific subsidiaries, each with its own branding, provider portals, credentialing contacts, and authorization workflows. A provider credentialed with WellCare in Florida may need to separately credential with Buckeye in Ohio or Home State Health in Missouri, even though all are owned by Centene. Each subsidiary operates under its state Medicaid contract with distinct requirements and processes.

Centene's Medicaid plans are state-contracted managed care organizations serving Medicaid-eligible populations, while Ambetter is Centene's Affordable Care Act marketplace brand for individuals purchasing coverage through state or federal exchanges. The two product lines have different benefit structures, provider networks, authorization requirements, and reimbursement rates. Providers must confirm which Centene product the member is enrolled in to apply the correct billing and authorization processes.

Denial rates vary significantly by state subsidiary, service type, and provider compliance with authorization requirements. Common denial reasons include missing prior authorization, documentation not supporting medical necessity, and billing code errors. Providers should verify authorization before admission, submit clinical documentation aligned with state-specific criteria, and confirm member eligibility on the date of service.

Each Centene subsidiary manages its own credentialing independently, even though most use CAQH ProView as the credentialing data source. You must generally apply separately to each state subsidiary where you want to participate as an in-network provider. Keep your CAQH ProView profile current and attested, then contact each subsidiary's provider enrollment department to initiate the credentialing process. Timelines typically range from approximately 90 to 120 days per subsidiary, though this can vary.

Key Billing Concepts

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This guide is provided for informational purposes only and does not constitute legal, regulatory, or professional advice. Payer requirements, phone numbers, and portal URLs are subject to change. Always verify current information directly with the payer. is not affiliated with the insurance companies described on this page.

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