At WellCare, we value everything you do to deliver 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, more fulfilling life. We continually invest in people and programs, innovate and work hard to remove barriers to care.
We will work with you and your staff to identify members with open care gaps, and we will reward you for closing those gaps. The attached provider manual is your guideline for working with us. We hope you find this a useful tool. The highlighted area on the right shows portions of the manual that speak directly to our shared goal of delivering quality care.
Welcome to Children’s Medical Services Health Plan
Provider and Member Administrative Guidelines
Quality Improvement
Utilization Management (UM), Case Management (CM) and Disease
Please refer to the Provider Participation Agreement (the Agreement) or contact a Provider Relations representative for clarification of the following. Support the Provider Relations, Provider Services, Clinical Services, and Marketing and Sales departments, as well as the tools and resources available on WellCare's website at www.wellcare.com/Florida/Providers. Maintain the panel for all CMS Health Plan members to whom services were provided prior to panel closure.
All newly enrolled members may access the Member Handbook on the CMS Health Plan website at www.wellcare.com/Florida/Members?Medicaid-Plans/CMS/CMS-19 and may request a paper copy by contacting Member Services to request a copy of manual. Access the secure online provider portal on the WellCare website at www.wellcare.com/Florida/Providers. Upon completion of the comprehensive assessment, a care plan is developed with input from the member and his/her guardian, the provider, and the CMS Health Plan Care Manager.
Necessity criteria in context with the Member's individual circumstances and the capacity of the local Provider delivery system. The Member or Provider may request a copy of the criteria used for a specific determination of Medical Necessity by contacting Utilization Management. In the event of an adverse benefit determination, we will notify the Member and the requesting Provider in writing of the determination.
Emergency Service Providers will make a reasonable effort to notify WellCare within 24 hours of the Member's presentation for emergency behavioral health services.
Claims
For more information on paper claims submission, refer to the Quick Reference Guide WellCare's website at www.wellcare.com/Florida/Providers/Medicaid. For more information about covered services under WellCare's Florida Medicaid plans, please refer to WellCare's website at www.wellcare.com. Information about the ICD-10 transition and codes can also be found at www.wellcare.com/Florida/Providers/ICD10-Compliance.
For more information about EDI implementation with WellCare, please refer to the WellCare Companion Guides available on the WellCare website at. For a list of WellCare's contracted clearinghouse(s), for information about the unique WellCare Payer Identification (Payer ID) numbers used to identify WellCare in electronic claim submissions, or to contact WellCare's EDI team , please refer to the Provider Resource Guide, which may be found on WellCare's website at. For more information about EDI implementation with WellCare, see the WellCare Companion Guides on the WellCare website at.
For assistance in setting up an EDI process, contact the WellCare EDI team by referring to the Quick Reference Guide on the WellCare website at. For more information on submitting appointments electronically, refer to the accompanying WellCare guides which can be found on the WellCare website at. Vendors and delegated providers can submit their appointment information directly to WellCare using WellCare's Direct Data Entry (DDE) portal.
The DDE tool can be found on the secure, online Provider Portal at www.wellcare.com/Florida/Providers. For more information about free DDE options, see the Florida Medicaid Provider Resource Guide on WellCare's website at www.wellcare.com/Florida/Providers/Medicaid. To start the process, refer to the Quick Reference Guide on WellCare's website at www.wellcare.com/Florida/Providers/Medicaid.
For more information about how to contact Provider Services, see the Quick Reference Guide on WellCare's website at www.wellcare.com/en/Florida/Providers/Medicaid.
Credentialing
Appeals and Grievances
Providers are required to keep a copy of the informed consent form in the member's medical record. Once the credentialing process has been completed, a timely notification of the credentialing decision is forwarded to the Provider. Upon receipt of a written request, WellCare will provide the practitioner with written information on the status of credentialing/re-credentialing.
Verbally informs the member of the decision by the end of working hours on the day the decision is made.
Compliance
Make available and/or distribute DOH-approved marketing materials as long as the Provider and/or the facility distributes or makes available marketing materials for all Managed Care Plans with which the Provider participates. If a Provider agrees to make available and/or distribute Marketing Materials for a Managed Care Plan, it must do so with the understanding that it must accept future requests from other Managed Care Plans in which it participates. Refer their patients to other sources of information, such as the Managed Care Plan, the enrollment broker, or the local Medicaid Area Office.
Making telephone calls to solicit, encourage or persuade recipients to enroll in the Managed Care Plan based on the Provider's financial or other interests. Providing lists to the Managed Care Plan of their Medicaid patients or Managed Care Plan membership. Providers may announce new or continued affiliations with the Managed Care Plan through general advertising (e.g., radio, television, websites).
Providers may make one announcement to patients of a new affiliation that mentions only the Managed Care Plan when such announcement is made via direct mail, email, or telephone. Additional direct mail and/or email communications from Providers to their patients regarding relationships must include a list of all Managed Care Plans with which the Provider contracts. All communications materials for member organizations that contain specific information about the Managed Care Plan (e.g., benefits, forms) must be pre-approved by the Agency.
For multiple managed care plans, either one managed care plan may submit the material on behalf of all other managed care plans, or the portion may be submitted and approved by the agency prior to use for each managed care plan. Care plans and listing only the names and/or contact information of the managed care plan do not require agency approval. Providers can distribute state-approved printed information provided by the managed care plan to their patients and compare the benefits of all the different managed care plans with which the providers contract.
The managed care plan must ensure that:. i) Materials do not "rank" or highlight specific Managed Care Plans and contain only objective information. ii) Such materials are consistent with all Managed Care Plans involved in the comparison and are approved by the Agency prior to distribution. iii) The Managed Care Plans identify a lead Managed Care Plan to coordinate submission of the materials.
Delegated Entities
Behavioral Health
Pharmacy
Details of the company's ethics and compliance program can be found on our website at www.wellcare.com/Florida/Corporate/About-Us. In addition, the involvement of prescribers and members is essential for the pharmacy program to be a success.
Definitions
The Department of Health and Human Services, which provides for the administration and funding of Medicare under Title XVIII, Medicaid under Title XIX, and the National Children's Health Insurance Program under Title XXI of the Social Security Acts. For purposes of providing behavioral health services, means members under the age of 18, as defined in The Children's Health Insurance Program (CHIP) refers to the health assistance program authorized by Title XXI of the Social Security Act.
Children's Medical Services Health Plan (CMS Plan/DOH) refers to a CHIP health plan authorized in Chapter 409, Part II, F.S. A Medicaid Specialty Plan for children with chronic conditions operated by the Florida Department of Health's Children's Medical Services as specified in section F.S., through a single, statewide contract with AHCA that is not subject to Statewide Medicaid Managed Care program (SMMC) purchasing requirements, or regional plan limits, but must meet all other plan requirements for the Managed Medical Assistance (MMA) program. The Medicaid Specialty Plan described herein is operated by the Florida Department of Health's Children's Medical Services under contract with WellCare (Provider).
Clean Claim means a claim for Covered Services that a) is received by WellCare in a timely manner, b) can be processed without obtaining additional information from the Provider of the service or from a third party, and c) is not subject to coordination of benefits or subrogation not issues. CLIA means the federal legislation commonly known as the Clinical Laboratories Improvement Amendments of 1988 as found in Section 353 of the federal Public Health Service Act (42 U.S.C a) and regulations promulgated thereunder. Department of Health refers to the state agency responsible for public health, public primary care and personal health, disease control, and licensing of health professionals, including pediatric medical services as specified in section F.S (CMS Plan).
If such a condition exists, emergency services and care include the care or treatment necessary to relieve or eliminate the emergency medical condition within the facility's service capacity. When deciding on medical necessity, the agency must, to the greatest extent possible, use a doctor in active practice, either employed by or on contract with the agency, of the same specialty or subspecialty as the examined doctor. Periodicity Schedule means the schedule that defines age-appropriate services and time frames for screenings within the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.
Service Location means any location where a Member may obtain any health care service covered by WellCare under the terms of the Provider Contract.
CMS Health Plan Resources