January 2015 Web Address: georgia.wellcare.com/provider/resource Important Telephone Numbers

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January 2015 Web Address: georgia.wellcare.com/provider/resource Important Telephone Numbers

Provider Services 1-866-231-1821 Eligibility Verification, Provider Complaints, Translation,

Transportation Services and Utilization Management

Nurse Advice Line 1-800-919-8807 Members may call this number to speak with a

nurse 24 hours a day, 7 days a week.

TTY Services 1-877-247-6272 Risk Management

WellCare Fraud, Waste and Abuse Hotline 1-866-678-8355 Georgia Medicaid Program Integrity 1-800-533-0686 Care and Disease Management Referrals 1-866-635-7045

Care Management Referrals [email protected] Provider Resource Guide

Claim Submissions Claim Payment Disputes

Provider Services 1-866-231-1821 Questions related to claim submissions

For EDI questions and assistance, please contact our EDI team who will help identify, test and correct any issues: [email protected]

Preferred EDI Partner EDI Payer ID

RelayHealth (McKesson) 14163 1-877-411-7271 Encounter Data Submissions 59354

WellCare follows the Centers for Medicare and Medicaid Services’ (CMS) guidelines for paper claim submissions. Since Oct. 28, 2010, WellCare accepts only the original red claim form for claim and encounter submissions.

WellCare does not accept handwritten, faxed or replicated claim forms.

Claim forms and guidelines may be found on our website at georgia.wellcare.com/provider/claimsupdates Mail paper claim submissions to:

WellCare Health Plans, Inc.

Claims Department P.O. Box 31224 Tampa, FL 33631-3224

The claim payment dispute process is designed to address claims when there is disagreement regarding reimbursement. Claim payment disputes must be submitted to WellCare in writing within 90 days of the date of denial on the EOP.

Mail or fax the written claim payment dispute and documentation to:

WellCare Health Plans, Inc. Fax 1-877-277-1808 Attn: Georgia Claim Payment Disputes

P.O. Box 31370 Tampa, FL 33631-3370

Claims Payment Policy Disputes

The Claims Payment Policy Department has created a new mailbox for provider issues related strictly to payment policy issues. Disputes for payment policy related issues (EOP Codes beginning with CEXXX, IHXXX, MKXXX or PDXXX) must be submitted to WellCare in writing within 90 days of the date of denial on the EOP.

Mail or fax all disputes related to payment policy issues to:

WellCare Health Plans, Inc. Fax 1-877-277-1808 Payment Policy Disputes Department

P.O. Box 31426 Tampa, FL 33631-3426

Appeals (Medical)

Providers may seek an appeal through the Appeals Department within 30 calendar days of a claim denial for lack of prior authorization, services exceeding the authorization, insufficient documentation or late notification.

WellCare Health Plans, Inc. Fax 1-866-201-0657 Attn: Appeals Department

P.O. Box 31368 Tampa, FL 33631-3368

Grievances

Member grievances may be filed orally by contacting Customer Service or submitted via fax or mail. Providers may also file a grievance on behalf of the member with the member’s written consent. Mail or fax member grievances to:

WellCare Health Plans, Inc. Fax 1-866-388-1769 Attn: Grievance Department

P.O. Box 31384 Tampa, FL 33631-3384

Non-Medicare Member Appointment of Representative Statement

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January 2015 Web Address: georgia.wellcare.com/provider/resource Pharmacy Services

Pharmacy Services 1-866-269-5251 Including after-hours and weekends (Catamaran)

Rx BIN Rx PCN Rx GRP Georgia Medicaid 603286 01410000 726257 Georgia Family Planning 603286 01410000 736257

Exactus™ Pharmacy Solutions 1-866-458-9246 [email protected] TTY 1-866-507-6135 Fax 1-866-458-9245 Medication Appeals Fax 1-888-865-6531 Mail medication appeal forms with supporting documentation to:

WellCare Health Plans, Inc.

Attn: Pharmacy Appeals Department P.O. Box 31398

Tampa, FL 33631-3398

Medication appeals may also be initiated by calling Provider Services. Please note that all appeals filed orally also require a signed, written appeal.

PDL Inclusions

To request consideration for inclusion of a drug in WellCare’s PDL, providers may write WellCare explaining the medical justification.

WellCare Health Plans Clinical Pharmacy Department Director of Formulary Services

Pharmacy and Therapeutics Committee P.O. Box 31577

Tampa, FL 33631-3577

Coverage Determination Requests Fax 1-866-455-6558 Submit aCoverage Determination Request Form for:

• Drugs not listed on the Preferred Drug List (PDL)

• Drugs listed on the PDL with a Prior Authorization (PA)

• Duplication of Therapy

• Prescriptions that exceed the FDA daily or monthly quantity limits (QL)

• Most self-injectable and infusion drugs (including chemotherapy) administered in a physician’s office

• Drugs that have an age limit (AL)

• Brand name drugs when an equivalent generic exists

• Drugs that have a step edit (ST) and the first-line therapy is inappropriate Web-based information:

georgia.wellcare.com/provider/pharmacyservices

• Pharmacy Services Overview

• WellCare of Georgia Preferred Drug List (PDL)

• Authorization Lookup Tool

• Participating Pharmacies

• Pharmacy Services Forms

Behavioral Health

Urgent Authorizations and Provider Services 1-800-424-5412 Outpatient Authorization Request Submissions Fax 1-888-871-0590 Inpatient Hospitalization Clinical Submissions Fax 1-888-361-6574

• Emergency behavioral health services do not require authorization. Inpatient admission notification is required on the next business day following admission.

• Inpatient concurrent review is done telephonically or via fax. Psychological testing requests are to be submitted via fax. All other levels of care requiring registration, including outpatient services, can be submitted online. Outpatient authorization and concurrent review is done via fax.

CareCore National Programs

CareCore National is our in-network vendor for the following programs: Advanced Radiology, Cardiology, Lab Management , Pain Management and Sleep Diagnostics.

Contact CareCore for all authorization-related submissions for the services listed above rendered in outpatient places of service.

Please click on the hyperlinks above for a listing of the specific services and related criteria included in the CareCore programs.

Urgent Authorizations and Provider Services 1-888-333-8641 Authorization Request Submissions Fax 1-866-896-2152

Web submissions may be done via the CareCore Provider Web Portal. A searchable Authorization Lookup and Eligibility Tool is also available online.

Contracted Networks

Vision – Optometry and Ophthalmology 1-866-522-5923 Avesis

Facility (e.g., hospital or ambulatory surgery center) and anesthesia claims should still be submitted directly to WellCare for reimbursement.

Dental Services – Avesis 1-800-231-0979

Transportation Non-Emergency Transportation (NET)

Non-emergency transportation is a benefit offered by Georgia Department of Community Health. Please click on the link above for information about the program, including contact information for the transportation vendors.

Outpatient Physical, Occupational and Speech Therapy Services will be handled by:

Therapy Network of Georgia Phone 1-855-825-7818 Fax 1-855-597-2697

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January 2015 Web Address: georgia.wellcare.com/provider/resource

Prior Authorization (PA) Requirements

This WellCare PA list supersedes any lists that have been distributed to our providers. Please ensure that older lists are replaced with this updated version.

Authorization changes are denoted by a  symbol for easy identification. Requirements that have been edited for clarification only are denoted with a  symbol.

All services rendered by nonparticipating providers and facilities require authorization. Primary care physicians must refer members to participating specialists. It is the responsibility of the provider rendering care to verify that the authorization request has been approved before services are rendered.

A searchable Authorization Lookup Tool is available on our website at: georgia.wellcare.com/auth_lookup.

WELLCARE’S PRIOR AUTHORIZATION (PA) LIST:

Urgent Authorization Requests and Admission Notifications – Call

1-866-231-1821

and follow the prompts.

• Notify us of unplanned inpatient hospital admissions by the next business day following admission (except normal maternity delivery admissions).

Telephone authorizations must be followed by a fax submission of clinical information – by the next business day.

• Outpatient authorizations may be requested by phone for urgent and time-sensitive services when warranted by the member’s condition. Please have CPT and ICD-9 codes available. Standard authorization requests may be submitted online or via fax using the numbers listed below.

Place-of-service codes (POS)* are specified for some services.

*Place of Service Codes

11 – Office 31 – Skilled Nursing Facility 65 – End Stage Renal Disease Treatment Facility

12 – Home 32 – Nursing Facility 71 – Public Health Clinic

20 – Urgent Care Facility 33 – Custodial Care Facility 72 – Rural Health Clinic

21 – Inpatient Hospital 49 – Independent Clinic 81 – Independent Laboratory

22 – Outpatient Hospital 50 – Federally Qualified Health Center

23 – Emergency Room 61 – Comprehensive Inpatient Rehabilitation Facility 24 – Ambulatory Surgery Center 62 – Comprehensive Outpatient Rehabilitation Facility

PROCEDURES and SERVICES

 = New or changed requirement

 = Clarification of current requirement

Authorization Required

Authorization No

Required Comments

DME Services Fax 1-877-431-8859

Durable Medical Equipment Purchases and Rentals X All DME rentals require authorization. DME purchase items reimbursed at OR below $250 per line item do NOT require authorization.

Hearing Aids and Devices X Contact Provider Services regarding benefit limitations.

Orthotics and Prosthetics X Purchase items reimbursed at OR below $500 per line item do

NOT require authorization.

Home Health Services Fax 1-866-886-4321

Home Health Care Services X

Inpatient Services Fax 1-877-431-8860

Acute Behavioral Health X

Alcohol and Substance Abuse Admissions X

Crisis Stabilization Services See Comments See Comments Please reference Prior Authorization Grid

Elective Inpatient Admissions (21)* X Clinical updates required for continued length of stay.

Electroconvulsive Therapy (ECT) X

Emergency Behavioral Health Services (23)* X

Emergent Care Services (23)* X

Emergency Transportation X

Inpatient Hospital Admissions (21)* X Clinical updates required for continued length of stay.

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January 2015 Web Address: georgia.wellcare.com/provider/resource

Long-Term Acute Care Hospital (LTACH) Admissions X Refer to Clinical Coverage Guidelines

NICU/Sick Baby Admissions X Notification required by the next business day following

admission. Clinical updates required for continued length of stay.

Observation Stays (22)* See Comments See Comments

Observation services will not require authorization; however, preplanned procedures will be subject to outpatient authorization requirements.

Authorization Lookup Tool

Clinical updates required for continued length of stay.

Rehabilitation Facility Admissions (61 & 62)* X Clinical updates required for continued length of stay.

Residential Treatment X

Skilled Nursing Facility Admissions (31)* X Clinical updates required for continued length of stay.

Outpatient Services Fax 1-866-455-6487

Advanced Radiology Services: CT, CTA, MRA, MRI, Nuclear Cardiology, Nuclear Medicine, OB Ultrasounds,

PET & SPECT Scans X

Contact CareCore National for authorization:

CareCore Provider Web Portal Phone: 1-888-333-8641

No authorization required for the initial 3 OB ultrasounds:

Advanced Radiology Program Criteria Ambulatory Surgery Center Services (24)*

Please see Authorization

Lookup Tool Authorization Lookup Tool

Assertive Community Treatment (ACT) X

Behavioral Health Services See Comments See

Comments

• Some behavioral health outpatient services require prior authorization. Please see Prior Authorization Grid.

• Some services may require annual registration. Please refer to the BH Initial Service Request Form. Cardiology Services: Cardiac Imaging, Cardiac

Catheterization, Diagnostic Cardiac Procedures and

Echo Stress Tests X

CareCore Provider Web Portal Phone: 1-888-333-8641 Cardiology Program Criteria

Community Mental Health Services X

Cytogenetic, Reproductive and Molecular Diagnostic Laboratory Testing

Note: Some tests are handled by CareCore. Please refer to Lab Management section below as well.

X Refer to Clinical Coverage Guidelines

Dialysis

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January 2015 Web Address: georgia.wellcare.com/provider/resource

Domiciliary, Rest Home and Custodial Care Admissions X

Electroconvulsive Therapy (ECT) X

Hospice Care Services X

Intensive Outpatient Program (IOP) X

Laboratory (Routine) Services (11, 22 & 81)* X Testing must be consistent with CLIA guidelines.

Laboratory Management

(Certain Molecular and Genetic Tests) X

WellCare Lab Management Criteria New Technology, Investigational or Experimental

Procedures X Refer to Clinical Coverage Guidelines

Office Procedures (11)* Please see

Authorization

Lookup Tool Authorization Lookup Tool Ophthalmology Procedures

Lookup Tool Authorization Lookup Tool Outpatient Hospital Procedures (22)*

Pain Management Services X

Pain Management Program Criteria

Partial Hospitalization Program (PHP) X

Pharmacological Management X

Psychological Testing X

Psychotherapy X

Radiology Anesthesia X Applicable CPT code range: 01916–01933

Radiology (Routine) Services (11, 22 & 24)*

Lookup Tool Authorization Lookup Tool Respiratory Therapy Services

Routine Primary Care Services (11 only)* X Pertains to services rendered in the office setting by a general and/or family practice provider, OB/GYN, internal medicine specialist and/or pediatrician

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January 2015 Web Address: georgia.wellcare.com/provider/resource

Sleep Diagnostics X

CareCore Provider Web Portal Phone Number 1-888-333-8641 Sleep Diagnostics Program Criteria

Sterilizations X Informed Consent for Voluntary Sterilization Required

Termination of Pregnancy Please see

Authorization Lookup Tool

Certificate of Medical Necessity Required (DMA-311) for Payment

Urgent Care Services (20)* X

Prenatal Notifications Fax 1-877-647-7475

Obstetric Global Services X Pregnancy Notification Form

Skilled Therapy Services Fax 1-855-597-2697

Occupational, Physical and Speech Therapy Services

(11, 12, 22 & 62)* See Comments

Please contact Therapy Network of Georgia for all outpatient occupational, physical and speech therapy requests.

Phone: 1-855-825-7818 Fax: 1-855-597-2697

Proudly Serving Georgia Families^® and PeachCare for Kids^® members.