At WellCare, we appreciate everything you do to provide quality care to our members – your patients. Through our collective efforts, we ensure that our members continue to trust us to help them in their quest for a longer and more fulfilling life. We are constantly investing in people and programs, innovating and working hard to remove barriers to care.
We will work with you and your staff to identify members with outstanding care gaps and reward you for closing those gaps. We hope you find it a useful resource, and the areas highlighted to the right are sections of the manual that directly address our shared goal of providing quality care.
Internal Claims and Appeals, Grievances and External Review Processes
WellCare's Customer Service Department is responsible for any necessary follow-up calls to the Member. WellCare will decide and notify the Member and Provider by telephone within 72 hours of receiving the request. WellCare will make a determination and provide notice to the Member and Provider, by telephone and in writing.
The PCP must document the reason for the referral and the name of the specialist in the Member's Medical Record. Whenever a WellCare Provider or other WellCare representative directs a Member to seek emergency services within or outside the coverage of the Member's WellCare plan. The frequency of on-site and/or telephone review will be based on the Member's clinical condition.
Services for ongoing processing from the non-participating provider for up to 60 days from the effective date of the member's contract. The member's complaint must be submitted to us within 180 days of the event that caused dissatisfaction. WellCare makes a decision and notifies the member and the prescribing provider within 24 hours of WellCare's receipt of the request.
At the member's request, WellCare can send a copy of the entire case file to the member.
Compliance
Please refer to the CMS website for more information about ICD-10 codes at www.cms.gov. Information on the transition and ICD-10 codes can also be found at www.wellcare.com/New-York/Providers/ICD10-Compliance. WellCare's Code of Conduct and Business Ethics Policy can be found at www.wellcare.com/New-York/Corporate/Compliance.
The Code of Business Conduct and Ethics is the foundation of iCare, WellCare's Corporate Ethics and Compliance Program. It describes WellCare's firm commitment to comply with the laws and regulations governing WellCare's business and accepted standards of business integrity. All associates, participating providers and other contractors must familiarize themselves with WellCare's Code of Conduct and Business Ethics.
WellCare employees, covered persons, participating providers and other suppliers of WellCare are encouraged to report compliance concerns and any suspected or actual wrongdoing using the Compliance Hotline at Detection tools have been developed to identify patterns of healthcare use, including overutilization, segregation, upcoding, abuse of modifiers, and other common schemes. Providers are cautioned that disassembly, fragmentation, recoding, and other activities designed to manipulate codes contained in the International Classification of Diseases (ICD), Physicians' Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and/or universal billing revenue .
In addition, providers are reminded that medical records and other documentation must be legible and support the level of care and service indicated on claims. Providers who engage in fraud, waste and abuse may be subject to disciplinary and corrective action, including warnings, monitoring, administrative sanctions, suspension or termination of authorized provider status, loss of license and/or civil and/or criminal penalties, but not limited to them. prosecution, fines and other penalties. To report suspected fraud, waste and abuse, see the State Quick Reference Guide on the WellCare website at
The practice should ensure that a procedure or process is in place to maintain the confidentiality of member records and other PHI as defined in HIPAA, and the practice follows those procedures and/or obtains appropriate permission from members to release information or medical records, where required by applicable state and federal law. Employees who have access to member records and other confidential information must sign a confidentiality statement. Providers can contact Provider Services by referring to the state-specific Quick Reference Guide on WellCare's website at www.wellcare.com/New-York/Providers/Health-Insurance-Marketplace.
Delegated Entities/Subcontractors
Review and initiate recommendations to senior management and the Chief Compliance Officer for recall and/or termination of those entities that do not meet the expectations of the current contractual agreement and regulatory requirements of WellCare's Medicare and Medicaid program.
Behavioral Health
Pharmacy
See the Member Summary of Benefits and Coverage for the exact cost sharing available on the WellCare website at
Definitions and Acronyms
Covered services means medically necessary services covered by the benefit plan, including basic health benefits and preventive health services. It is not experimental or investigational or otherwise excluded or limited by the Member's Policy or any amendment or supplement attached to the Member's Policy. The deductible is the amount a member must pay in a calendar year for covered services before WellCare will cover or pay for those services at applicable copayment or coinsurance amounts.
If required by law, the member will pay no deductible or cost sharing for preventive services included in the federally essential health benefits. Maximum Out-of-Pocket (MOOP) is the sum of the deductible, prescription drug deductible (if applicable), co-pay and co-insurance as shown in the member's overview of coverage. Medical Record means any written, printed or electronically recorded material maintained by a Provider in the course of providing health services to a Member regarding the Member as a patient and the services rendered.
Medical necessity means health care items and services that: (1) are clinically appropriate in terms of type, frequency, extent, location, and duration and are considered effective for the member's illness, injury, or disease; (2) necessary for the direct care and treatment or management of that condition; (3) failure to provide services would adversely affect the member's condition; (4) provided in accordance with generally accepted standards of medical practice; (5) not primarily for the convenience of the Member or Provider; and (6) is not more expensive than an alternative service or set of services likely to produce equivalent therapeutic or diagnostic results. If services can be safely provided to a member in a lower cost setting, those services will not be medically necessary if performed in a higher cost setting. Member means a Qualified Individual who is properly enrolled in the Basic Plan and is entitled to receive Covered Services at the time those Services are rendered, and may include the Member's Dependents.
Plan means WellCare of New York, Inc., which provides benefits to Members for the Covered Services described in the Member's policy. Preventive health services shall be defined by 45 CFR 147.130, and WellCare may use reasonable medical management techniques to determine the frequency, method, treatment or institution of preventive health services to the extent not specified in the recommendations or guidelines specified in 45 CFR 147.130. Provider means an individual or entity that has directly or indirectly contracted with WellCare to provide or arrange for the provision of Covered Services to Members pursuant to a benefit plan.
A provider includes, but is not necessarily limited to, a hospital, physician or specialist, health care professional, podiatrist, psychologist, clinical social worker, occupational or physical therapist, physician assistant, or advanced practice registered nurse who is licensed, certified, or otherwise legally permitted to provide covered services to members in accordance with the member's policy. Referral means the process by which the member's primary care provider directs the member to seek and obtain covered services from other providers. Service Area means the geographic area within the state in which WellCare is authorized by the state department of insurance or other state agency to offer the Essential Plan.
WellCare Resources
