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 highlighted areas to the right are sections of the manual that directly address our shared goal of providing quality care.
Welcome to WellCare
Provider and Member Administrative Guidelines
Quality Improvement
Utilization Management, Care Management and Disease Management
WellCare's customer service department is responsible for any necessary follow-up calls to the member. WellCare will make a decision and notify the member and provider by phone within 72 hours of receiving the request. WellCare will make a decision and notify the member and provider, by phone and in writing.
If a participating WellCare provider is selected, the PCP will issue a referral to the member for a visit. The PCP must document the reason for the referral and the name of the specialist in the member's medical record. Any time a WellCare provider or other WellCare representative directs a member to seek emergency services within or outside of the member's WellCare plan coverage.
The frequency of on-site and/or telephone examinations will be based on the member's clinical condition. A member may continue to provide care through delivery and all postpartum services directly related to delivery. Care managers work closely with the provider on when to discharge a member from the care management program.
Claims
Unless prohibited by law or regulation, WellCare may refuse payment of any claim that does not meet WellCare's clean claim submission requirements or failure to timely submit a clean claim to WellCare. If a claim is denied due to lack of compliance with WellCare's claim submission requirements, the denied claim must be resubmitted within the timely submission limits. For more information on paper filing of claims, refer to the state-specific Quick Reference Guide on the WellCare website at.
For more information on EDI implementation with WellCare, refer to WellCare's Companion Guides on WellCare's website at. For a list of clearinghouses that WellCare uses, for information about WellCare's unique payer ID numbers used to identify WellCare on electronic claims submissions, or to contact WellCare's EDI team, refer to the Provider Resource Guide on WellCare's website at www.wellcare.com/New-York/Providers/Health-Insurance-Market. To promote consistency and efficiency for all claims and encounter submissions to WellCare, it is WellCare's policy that these requirements apply to all paper and direct data entry (DDE) transactions.
For help creating an EDI process, see the state-specific Quick Reference Guide on WellCare's website. WellCare will pay or deny a clean claim within 30 days of WellCare's receipt of the clean claim. To submit other insurance information electronically, refer to the WellCare Companion Guides on WellCare's website at.
If benefits are coordinated with an insurance company other than primary and the payment amount equals or exceeds WellCare's liability, no additional payment will be made through provider preventable conditions. For institutional claims, the Provider must include WellCare's original claim number and bill the frequency code according to industry standards. For professional claims, the Provider must include WellCare's original claim number and billing frequency code per industry standards.
WellCare's medical director will decide whether the proposed complication merits additional compensation above the normal allowable amount. For more information about contacting provider services, see the Quick Reference Guide on the WellCare website at www.wellcare.com/New-York/Providers/Health-Insurance-.
Credentialing
Internal Claims and Appeals, Grievances and External Review Processes
The member's complaint must be submitted to us within 180 days of the event causing dissatisfaction. WellCare will make a decision and notify the member and the prescribing provider no later than 24 hours after WellCare receives the request. At the Member's request, WellCare can send the Member a copy of the complete file.
Compliance
For more information about ICD-10 codes, see the CMS website at www.cms.gov. ICD-10 transition information and 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 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.
Suppliers who engage in fraud, waste and abuse may be subject to disciplinary and corrective action, including, but not limited to, warnings, monitoring, administrative sanctions, suspension or termination as an authorized Supplier, loss of license and/or civil and/or criminal prosecution, fines and other penalties. To report suspected fraud, waste and abuse, please refer to the state-specific Quick Reference Guide on WellCare's website at. The practice must ensure that there is a procedure or process in place for maintaining confidentiality of Member Medical Records and other PHI as defined under HIPAA, and the practice follows those procedures and/or obtains appropriate authorization from Members to access information or Medical Records release, where required by applicable state and federal law.
Employees who have access to members' medical records and other confidential information must sign a confidentiality statement. Providers can contact provider services by viewing the State Quick Reference Guide on the WellCare website at www.wellcare.com/New-York/Providers/Health-Insurance- Marketplace.
Delegated Entities
Review and initiate recommendations to Senior Management and the Chief Compliance Officer for revocation and/or termination of those entities that do not meet current contractual agreement expectations and WellCare's Medicare and Medicaid program regulatory requirements.
Behavioral Health
Pharmacy
For an exact cost breakdown, see the summary of benefits and coverage for members on the WellCare website at
Definitions and Acronyms
Covered benefits means medically necessary services that are covered by a benefit plan, including essential health benefits and preventive health services. Not experimental or investigational or otherwise excluded or limited by Member's policy or by any amendment or rider attached to Member's policy. Deductible is the amount the member is required to pay in a calendar year for covered services before WellCare covers or pays for those services at the applicable copayment or coinsurance amounts.
If required by law, the Member will not pay a deductible or cost sharing for preventive services that are part of federal essential health benefits. Maximum Out-of-Pocket (MOOP) is the sum of the deductible, prescription drug deductible (if applicable), copayment, and coinsurance as shown in the member's coverage summary. Medical record means any written, printed, or electronically recorded material maintained by a Provider in the course of providing health care services to a Member relating to the Member as a patient and the services provided.
Medical necessity means health care items and services that: (1) are clinically appropriate in terms of type, frequency, scope, site and duration, and are considered effective for the Member's illness, injury or disease; (2) required for the direct care and treatment or management of that condition; (3) the Member's condition would be adversely affected if the services were not provided; (4) provide in accordance with generally accepted standards of medical practice; (5) not primarily for the convenience of the Member or the Provider; and (6) not more expensive than an alternative service or series of services, which is at least as likely to produce equivalent therapeutic or diagnostic results. If services can be safely provided to the member in a lower cost environment, such services will not be medically necessary if performed in a higher cost environment. Member means a qualified individual duly enrolled in the Essential Plan and eligible to receive Covered Services when such services are rendered, and may include the Member's dependent.
Plan means WellCare of New York, Inc., which provides benefits to Members for the Covered Services described in the Member's policy. Provider means an individual or entity that has contracted, directly or indirectly, with WellCare to provide or arrange for the provision of Covered Services to Members under a benefit plan. The provider includes, but is not necessarily limited to, a hospital, physician or specialist, health care professional, pediatrician, psychologist, clinical social worker, occupational or physical therapist, physician assistant, or advanced registered nurse who is licensed, certified or legally permitted to provide Covered Services to Members under the Member's policy.
Referral means the process by which Member's primary care provider directs 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 Department of Insurance or other government agency to offer the Essential Plan.
WellCare Resources
