Overview
For product information, please refer to the Quick Reference Guide on the WellCare website at https://kentucky.wellcare.com/provider/resources. WellCare's website, https://kentucky.wellcare.com/, offers a variety of resources to assist caregivers and their staff.
Provider and Member Administrative Guidelines
See the Quick Reference Guide on WellCare's website at https://kentucky.wellcare.com/provider/resources; and. WellCare's customer service department is responsible for any necessary follow-up calls to the member.
Quality Improvement
Measuring board or vertical height measuring device for children 2 years of age or older;. PCP Responsibilities – The PCP is responsible for performing all required components of the EPSDT medical examination in accordance with the AAP and ACIP periodicity schedules and for appropriate documentation in the member's medical record. Any risk identified through a lead risk assessment should be documented in the medical record and addressed.
Results of TB risk assessment and tests as needed must be documented in the child's medical record. Each provider is required to maintain a primary medical record for each member that contains sufficient medical information from all providers involved in the member's care to ensure continuity of care. Consultation, laboratory, and x-ray reports must be filed in the medical record and must have documentation indicating review (ordering provider's initials);
Information from the medical record review can be used in the recredentialing process as well as in quality activities.
Utilization Management (UM), Care Management (CM) and
Providers may request a copy of the criteria used for the specific determination of medical necessity by calling the Provider Services department listed in the Quick Reference Guide on WellCare's website at https://kentucky.wellcare.com /provider/resources. It is the responsibility of the treating dentist to obtain prior authorization and to communicate the prior authorization number to the hospital. Transplant procedures and related services must be approved by WellCare prior to transplant, regardless of the member's age.
Eligibility and medical necessity, including that of the medical setting, must be clearly documented in the member's medical record. In the event of a proposed action, WellCare will notify the member in writing of the proposed action. Placing the individual's health (or, in the case of a pregnant woman, the health of the woman or her unborn child) at serious risk;.
A copy of the required sterilization consent form (MAP 250) is available on the WellCare website at https://kentucky.wellcare.com/provider/forms_and_documents.
Claims
For more information about filing claims on paper, see the Quick Reference Guide on WellCare's website at https://kentucky.wellcare.com/provider/resources. For more information about EDI implementation with WellCare, see the Wellcare Companion Guides on the WellCare website at https://kentucky.wellcare.com/provider/claims_updates. For more information about EDI implementation with WellCare, please consult the Wellcare Companion Guides on the WellCare website at.
For more information on electronic submission of encounters, refer to the WellCare Companion Guides on the WellCare website at For a list of WellCare contracted clearinghouses, refer to WellCare Job Aids on the WellCare website at For more information about free DDE options, refer to the Provider Resource Guide on WellCare's website at
For Provider Services contact information, please refer to the Quick Reference Guide on the WellCare website at https://kentucky.wellcare.com/provider/resources.
Credentialing
Upon receipt of a written request, WellCare will provide the practitioner with written information regarding the status of the credentialing/re-credentialing application, generally within 15 business days. At least one individual on the Panel shall be a participating provider and a clinical colleague of the practitioner who submitted the dispute. Notice of the adverse recommendation, along with the reasons for the action, and the practitioner's rights and process for obtaining first- and/or second-level Dispute Resolution Peer Review Panel processes, are provided to the practitioner.
Within five working days of the final adjournment of the Dispute Peer Review Board hearing, the medical director shall notify the physician of the results of the first-level board hearing. In the event that the findings of the first-level panel hearing are negative for the contractor, the contractor may access the second-level peer review panel by following the notice. Within five business days after the final adjournment of the hearing of the second-level mutual review board of disputes, the health director shall notify the provider of the results of the second-level board hearing by registered or overnight delivery.
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
This information will be made available to the member at the request of the member or the member's authorized representative. A provider may not file a complaint on behalf of the member without the member's written permission. WellCare will acknowledge the complaint of the member or the member's representative in writing within five working days from the date the complaint is received by WellCare.
Upon receipt of the complaint, a written resolution will be mailed to the member within 30 calendar days of the date WellCare receives the complaint. If an extension is not granted, WellCare will send a termination letter after resolution of the member's complaint. An extension of up to 14 calendar days may be requested by the member or the member's representative.
These records will be made available to the member upon request by either the member or the member's legal counsel.
Compliance
Details of the Corporate Ethics and Compliance Program can be found on WellCare's website at http://www.wellcare.com/AboutUs/default. WellCare's Code of Conduct and Business Ethics Policy can be found at http://www.wellcare.com/AboutUs/default. To report suspected fraud and abuse, refer to the Quick Reference Guide on WellCare's website at https://kentucky.wellcare.com/provider/resources 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 http://www.wellcare.com/AboutUs/default. Refer to Chapter 3: Quality Improvement for guidance on responding to WellCare's requests for member medical records for treatment, payment, and health care operations. For more information on how to request this information, members may contact WellCare Customer Service at the toll-free telephone number provided on the member's identification card.
Providers may contact WellCare Customer Service by viewing the Quick Reference Guide on the WellCare website at
Delegated Entities
Behavioral Health
Behavioral health providers are expected to help members access urgent, emergency and routine behavioral services as quickly as the member's condition requires. Behavioral providers are required to use the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) multiaxial classification when assessing the member for behavioral health services and document the DSM-IV diagnosis and assessment/outcome information in the member's medical record. PCPs may provide any clinically appropriate behavioral health service within the scope of their practice.
However, if they are unable to treat a member's physical health, behavioral health providers must refer members with known or suspected and untreated physical health problems or disorders to their physician for examination and treatment with the consent of the member or the member's legal guardian. 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 hospital stay summary letter).
Advisory Council information will be available on the WellCare website at https://kentucky.wellcare.com/provider/behavioral_health.
Pharmacy
To request consideration for adding a drug to WellCare's PDL, providers may write or fax WellCare, explaining the medical justification. To request an exception to the general mandatory policy, a coverage determination request form must be submitted. The first-line medications in WellCare's PDL have been evaluated using the clinical literature and approved by WellCare's P&T Committee.
To make a request verbally or in writing, please refer to the contact information in the provider's Quick Reference Guide on the WellCare website at. The injectable infusion form is on WellCare's website at https://kentucky.wellcare.com/Provider/Forms_and_Documents. For a complete list, please refer to the PDL on the WellCare website at https://kentucky.wellcare.com/provider/pharmacy.
To learn more about the conditions covered under Exactus Pharmacy Solutions, or how to contact them, refer to WellCare's website at.
Definitions and Abbreviations
EPSDT Special Services” means medically necessary services not otherwise covered by the Kentucky Medicaid Program under EPSDT Covered Services. Encounter Data” means the encounter information, data and reports for Covered Services provided to a member who meets the clean claims requirements. Member" means an individual duly enrolled in a benefit plan and eligible to receive Covered Services at the time such services are provided.
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. Provider” means an individual or entity that has contracted to provide or arrange for the provision of Covered Services to members pursuant to a benefit plan. 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 at which a Member may receive any Covered Service from a Provider.
WellCare Resources