Timeframe for retroactive or post-service initial decision has been changed from 30 calendar days to 14 calendar days. Section updated. Time frame changed from 45 calendar days to 120 calendar days from the final decision letter. Section updated.
Overview
Providers can contact the appropriate departments at WellCare by referring to the Quick Reference Guide on WellCare's website at. Providers can find the quick reference guide at www.wellcare.com/en/Kentucky/Providers/Medicaid.
Provider and Member Administrative Guidelines
Refer to the Quick Reference Guide on the WellCare website at www.wellcare.com/en/Kentucky/Providers/Medicaid; And. Providers can access the Cultural Competency Survey on WellCare's website at www.wellcare.com/Kentucky/Providers/Medicaid/Training.
Quality Improvement
Measuring board or device for measuring length or height in a lying position for infants and children up to 2 years;. Measuring board or device for measuring height in a vertical position for children 2 years of age or older;. WellCare expects the PCP to follow up with the referring provider to obtain documentation regarding the delivery of the immunization(s) in order to maintain an accurate and complete medical record.
Any risk identified through the lead risk assessment should be documented in the medical record and addressed. The results of the TB risk assessment and testing as needed should be documented in the child's medical record. Each Provider is required to maintain a primary medical record for each Member, which contains sufficient medical information from all providers involved in the Member's care to ensure continuity of care.
Consultation, laboratory, and radiology reports must be filed in the medical record and must have documentation indicating review (ordering provider's initials); Information from the record review can be used in the readmission process as well as quality activities.
Utilization Management (UM), Care Management (CM) and
Claims
The tools and resources available on WellCare's website at www.wellcare.com/en/Kentucky/Providers/Medicaid; and. For contact information, refer to the Quick Reference Guide on WellCare's website at www.wellcare.com/en/Kentucky/Providers/Medicaid. All forms are on WellCare's website at www.wellcare.com/Kentucky/Providers/Medicaid/Forms.
See the Quick Reference Guide on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid. Please see the Quick Reference Guide on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid for contact information. For contact information, refer to the Quick Reference Guide on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid.
For more information on the Care Management referral line, please refer to the Quick Reference Guide on the WellCare website at For more information on paper claims submission, refer to the Quick Reference Guide on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid. For more information on EDI implementation with WellCare, refer to the Wellcare Companion Guides on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid/Claims.
For a list of WellCare contracted clearinghouses, see the WellCare Resource Guides on the WellCare website at. For a list of WellCare contracted clearinghouses, see the WellCare Provider Resource Guide on WellCare's website at. For more information about free DDE options, see the Provider Resource Guide on WellCare's website at.
Credentialing
In such cases, WellCare is required to notify the Department of the reason(s) for termination. Such notice shall be given by the later of: (i) thirty (30) days prior to the effective date of termination or (ii) within fifteen (15) days after receipt of the notice. WellCare will notify any Member of Provider termination provided such Member has received service from the terminating Provider within the preceding six months.
At least one person on the panel will be a participating provider and a clinical peer of the practitioner who filed the dispute. Notice of the adverse recommendation, along with reasons for the action and the processor's rights and process for obtaining the first and/or second level of the dispute resolution panel processes, is given to the processor. The Medical Director shall, within five working days of the final adjournment of the dispute resolution panel hearing, notify the practitioner of the results of the first level panel hearing.
The medical director shall, within five working days of the final adjournment of the second-level dispute resolution panel hearing, notify the practitioner of the results of the second-level panel hearing by certified or registered mail. In the event that the results of the second-level peer review panel result in an adverse decision for the practitioner, the results of the second-level peer review panel shall be final.
Appeals and Grievances
The Member is also informed of the right to file a complaint if he does not agree with the plan request to expand the appeal file. This information will be made available to the Member at the request of the Member or the Member's authorized representative. The member or service provider shall timely file an appeal of WellCare's adverse benefits determination or the member shall request a fair hearing by the state within 120 days from the date WellCare provided notice of the adverse benefits determination;
The Provider may not file a complaint on behalf of the Member without the written consent of the Member. WellCare will accept the Member's or the Member's representative's complaint in writing within five business days of the date WellCare receives the complaint. Upon receipt of the complaint, a written resolution will be sent to the Member within 30 calendar days of the date the complaint was received by WellCare.
Unless an extension is selected, WellCare will send a closure letter once the member's grievance is resolved. An extension can be requested by the member or the member's representative for up to 14 calendar days.
Compliance
Protection from retaliation for employees and subcontractors who report suspected fraud, waste and abuse; And. Details of the Corporate Ethics and Compliance Program can be found on WellCare's website at www.wellcare.com/Kentucky/Corporate/Compliance. To report suspected fraud and abuse, see the Quick Reference Guide on WellCare's website at www.wellcare.com/Kentucky/Providers/Medicaid or call WellCare's confidential and toll-free compliance hotline.
Details about the Corporate Ethics and Compliance Program and how to contact the WellCare Fraud Hotline can be found on the WellCare website at www.wellcare.com/Kentucky/Corporate/Compliance. HIPAA provides for the release of WellCare members' medical records for payment and quality purposes and/or health plan operations. See Section 3: Quality Improvement for guidance on responding to WellCare's requests for members' health records for treatment, payment, and health activity purposes.
WellCare's Customer Service Department using the toll-free phone number found on the Member's ID card. Providers may contact the WellCare Customer Service Department by referring to the Quick Reference Guide on the WellCare website at.
Delegated Entities
Behavioral Health
In the event that a Member misses an appointment, the Behavioral Health Provider must contact the Member within 24 hours to reschedule. Behavioral health providers are expected to assist members in accessing emergent, urgent, and routine behavioral services as quickly as the member's condition requires. All behavioral health services will be provided in accordance with access standards established by the Department of Medicaid Services.
When assessing members for behavioral health services, the plan and its providers must use the most recent version of the DSM classification. PCPs may provide any clinically appropriate behavioral health service within the scope of their practice. However, if they are unable to treat the member's physical health, behavioral health providers should refer members with known or suspected and untreated physical health problems or disorders to their PCP for.
Behavioral health providers, with the consent of the member or the member's legal guardian, must submit an initial and quarterly report of the member's behavioral health status to the PCP. WellCare encourages behavioral health providers to pay particular attention to communication with the PCP at the time of discharge from an inpatient hospital stay (WellCare recommends that you fax the PCP a discharge instruction sheet or a letter summarizing the hospital stay).
Pharmacy
To request consideration for the addition of a drug to WellCare's PDL, providers may write or fax WellCare, explaining the medical justification. To request an exception to the mandatory generic policy, a Coverage Determination Application Form must be submitted. The clinical justification for why the generic alternative is not suitable for the Member must be included with the Coverage Determination Application Form.
For more information about the coverage determination review process, including how to access the coverage determination request form, see the Coverage Determination Review Process below. To submit a request, verbally or in writing, refer to the contact information provided in the Provider Quick Reference Guide on the WellCare website at. For a complete list, refer to the PDL on WellCare's website at www.wellcare.com/Kentucky/Providers/Medicaid/Pharmacy.
Contact information is also found in the Quick Reference Guide on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid. To learn more about the conditions covered by Exactus Pharmacy Solutions or how to contact them, please refer to WellCare's website at
Definitions and Abbreviations
Co-surgeon” means one of multiple surgeons working together as primary surgeons performing separate part(s) of a surgical procedure. Emergency Services” or “Emergency Care” means covered inpatient and outpatient services that are as follows: (1) provided by a Provider qualified to provide these services; and (2) necessary to evaluate or stabilize a medical emergency. Encounter Data" means encounter information, data and reports for Covered Services provided to a Member who meets the requirements for Clean Claims.
Member” means an individual duly enrolled in a benefit plan and eligible to receive Covered Services when such services are rendered. Periodicity Schedule” means the schedule that defines age-appropriate services and time frames for screenings within the Program for Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT). Prior Authorization” means the process of obtaining authorization prior to a planned inpatient admission or an outpatient procedure or service.
Screening” means the review of the health and health-related conditions of a recipient by a health care professional to determine whether further diagnosis or treatment is necessary. Service Location" means any location where a Member may obtain any Covered Services from a Network Provider.
WellCare Resources