Provider bulletins applicable to the Medicaid/NJ FamilyCare WellCare managed care plan may override the policies and procedures in this manual. To create an account, see the Provider Resource Guide on the WellCare website at www.wellcare.com/en/New-Jersey/Providers/Medicaid.
Provider and Member Administrative Guidelines
Providers must accept WellCare's payments for services, goods and supplies as payment in full on behalf of the member. Selected specialty services by a specialty Provider or specialty care center require an appropriate referral from the Member's PCP.
Member Administrative Guidelines
Quality Improvement
Quality Improvement
Utilization Management (UM), Care
Management (CM) and Disease Management (DM)
Utilization Management
Pre-authorization requirements by type of service can be found in the Quick Reference Guide on the WellCare website at See the Quick Reference Guide on the WellCare website at www.wellcare.com/New-Jersey/Providers/Medicaid.
Care Management Program
Care management activities, a component of care management, are a set of activities tailored to meet a Member's situational health-related needs. Members will have access to a specialty care provider through standing authorization requests, if appropriate Care Management Members are identified by the CNA. Developmental Disability (DDD), or Member's score 5+ on Initial Health Screening [IHS]), but does not agree to participate in the Care Management Program, the Member is placed in a care monitoring status.
For assistance with transition planning, the Provider may contact the Care Management toll-free line.
Disease Management Program
Claims
- O. Box 3 1584 Tampa, FL 33634
For more information on submitting claims, refer to the Quick Reference Guide on WellCare's provider website at For more information on EDI implementation with WellCare, refer to the WellCare Companion Guides on the WellCare website at For more information on submitting meetings electronically, refer to the WellCare Companion Guides on the WellCare website at
For more information on contacting WellCare customer service, please refer to the Quick Reference Guide on WellCare's provider website at
Credentialing
All Participating Providers or entities delegated for credentials must use the same standards as defined in this section and as set forth in the Agreement. In the event that the credential verification process reveals information submitted by the practitioner that differs from the verification information obtained by WellCare, the. WellCare Participating Providers (all disciplines) are required to carry and continue to maintain professional liability insurance within the minimum limits required by the State of New Jersey and as set forth in the Agreement, unless otherwise agreed to in writing by WellCare.
In the event that a sanction imposes a reprimand or probation, a written notice will be given to the Provider requesting a full explanation, which will then be reviewed by the Credentialing/Peer Review Committee.
Grievances and Appeals
Overview
Grievances
If additional information is required, a letter will be mailed to the Member describing the additional information requested and the reason for the additional information. The Member and the person who will represent the Member must sign the AOR statement. WellCare will send a written decision letter after the Member's appeal is complete (within 30 calendar days).
If a member requests continuation of benefits under the Medicaid Fair Treatment Process and the appeal is denied, they may be required to pay the cost of these services.
Provider Appeals
The provider must submit this request within 30 calendar days of receiving WellCare's written determination. Thereafter, the Provider shall have the right to submit the matter to binding arbitration (alternative dispute resolution for external review). The provider must submit a written request for an ADR review within 30 calendar days of receiving the adverse determination letter.
The provider has 30 days after receiving written notification of the final determination that the claim lacks sufficient evidence to submit the required evidence.
Member Appeals
If you call first, you must follow up your request over the phone by writing to WellCare Health Plans of New Jersey at the address in #2 above. You have the right to represent yourself, have someone else represent you, or have legal representation. Disability Rights New Jersey (DRNJ) at [email protected] or call DRNJ at TTY: 711) for free legal and advocacy services for people with disabilities; or.
Community Health Law Project (CHLP) at [email protected] or call CHLP to be directed to the appropriate office in your county.
O. Box 712
Compliance
WellCare’s Compliance Program
WellCare uses the ICD for diagnosis code validation and follows all CMS mandates for any future ICD changes, which include ICD-10 or its successor. Please refer to the CMS website for more information about ICD-10 codes at www.cms.gov and the ICD-10 Lookup Tool at. Information on transition and ICD-10 codes can also be found at www.wellcare.com/New-Jersey/Providers/ICD10-Compliance.
Code of Conduct and Business Ethics
To report suspected fraud and abuse, please refer to the Quick Reference Guide on WellCare's website at www.wellcare.com/New-Jersey/Providers/Medicaid or call the confidential and toll-free WellCare Compliance Hotline. Any communication with other clinical persons involved in the Member's health, medical and spiritual care. For more information on how to request this information, Members can contact Customer Service using the toll-free telephone number on the Member's ID card.
Providers can contact Provider Services by referring to the Quick Reference Guide on the WellCare website at www.wellcare.com/New-Jersey/Providers/Medicaid.
Cultural Competency Program and Plan
Delegated Entities
The Chief Compliance Officer has final authority over the membership of the Transfer Control Committee. Conducting ongoing monitoring activities to evaluate the entity's performance and compliance with regulatory requirements and accreditation standards. Conducting annual audits to verify entity and process performance supports ongoing compliance with regulatory requirements and accreditation standards.
Development and implementation of Corrective Action Plans (CAP) if the performance of the Delegated Entity is substandard or if the terms of the agreement are violated.
Behavioral Health
Behavioral Health Provider – Emergency Immediate Behavioral Health Provider – Urgent < 48 hours Behavioral Health Provider – Pos. 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 help Members access emergent, urgent, and routine behavioral services as quickly as the Member's condition requires.
Additional behavioral health resources and information are available on WellCare's website at www.wellcare.com/New-Jersey/Providers/Medicaid/Behavioral-Health.
Pharmacy
The first-line drugs on the WellCare PDL were evaluated using the clinical literature and approved by its P&T committee. For a complete list of covered OTC drugs, see the PDL on the WellCare website at www.wellcare.com/New-Jersey/Providers/Medicaid/Pharmacy. To make a verbal request, please contact the contact information listed in the Quick Reference Guide on the WellCare website at www.wellcare.com/New-Jersey/Providers/Medicaid.
The WellCare process for purposes of this section requires review and prior approval by DMAHS.
Definitions
Covered Services or Benefit Package means the health care services for which WellCare has agreed to provide, arrange and be fiscally responsible. Delegated services are certain health care plan functions under WellCare's contracts with the Centers for Medicare & Medicaid Services (CMS) and/or applicable state government agencies that are performed by an entity other than WellCare. Individuals with Special Health Care Needs (SHCN) means members who face daily physical, mental or environmental challenges that put their health at risk and whose ability to function fully in society is limited.
Members with special health care needs are members who face daily physical, mental or environmental challenges that compromise their health and whose ability to function fully in society is limited.
WellCare Resources
Addendum A: Managed Long Term Care (MLTSS)
Short-term nursing facility stays are available to MLTSS members receiving HCBS who require temporary placement in a nursing facility due to temporary illness, serious injury, wound care, or the absence of the primary caregiver and reasonable compensation is provided. The Community Maintenance Needs Allowance continues to apply during the provision of short-term care in a nursing facility to ensure that the member has sufficient resources to maintain his or her community home for purposes of return to the community. If it is determined before the end of the 180 day period (date after admission) that the member will not be released from the nursing facility, the member will be classified as an inmate.
The Member is automatically converted to custody status in the nursing facility if the member is in the nursing facility for more than 180 days.
Provider and Member Administrative Guidelines
No contact will be made if an MLTSS member is absent without notice from a program or service offered under MLTSS where WellCare, or its contracted MLTSS providers, including staff members and care managers, are unable to determine the member's location identify using the contact details. available in the member's file. If this is still unsuccessful, immediately notify the Member's MLTSS care manager. The Care Manager, upon receiving a notification of the event of failure to contact an MLTSS provider, will also attempt to contact the Member, including conducting a home visit on the same day of the notification to determine ensure the safety of the member. If attempts to contact the member are unsuccessful, WellCare will file a critical incident report through the designated state system.
WellCare identifies and tracks critical incidents and reviews and analyzes critical incidents to identify and address potential and actual care quality and/or health and safety issues.
Utilization Management (UM), Care Management (CM), Disease Management
Prior authorization may be granted for a series of visits or services related to an episode of care. The request for prior authorization must describe the plan of care, including the frequency and total number of visits requested and the expected duration of care. WellCare will also identify quality issues, usability issues, and the rationale behind not following WellCare's prior authorization/pre-certification guidelines.
The Care Manager may contact the MLTSS provider to develop a Plan of Care (POC).
Claims
The request for prior authorization must include the diagnosis to be addressed and the CPT code describing the expected procedure. The attending physician or designee is responsible for obtaining prior approval for the elective, non-urgent or non-emergency admission. WellCare will review post-service requests for authorization of inpatient admissions or outpatient services only if the member was ineligible at the time of treatment but was retroactively eligible for WellCare or in the event of emergency treatment and the payer is unknown at the time the treatment takes place. time of service.
The County Social Welfare Agency (CWA) will calculate the cost share for MLTSS eligible individuals on behalf of the State of New Jersey.
Credentialing
Providers must use the “1500” form for AL facilities, HCBS service providers, and non-traditional providers such as home improvement contractors, emergency response system providers, meal delivery providers, and more. Providers must use the “837 P” form for AL facilities, HCBS service providers, and non-traditional providers such as home improvement contractors, emergency response system providers, meal delivery providers, and more. MLTSS members living in an Assisted Living (AL) and/or NF setting may have a cost share as calculated by the County Welfare Agency and are responsible for paying the service provider the cost share.
The patient's cost share/payment obligation (PPL) will be deducted from NF and/or Provider AL payments.
Grievances and Appeals
Compliance
Delegated Entities
Behavioral Health
Addendum B: Orthodontic Services
In this case prior authorization must be submitted for comprehensive orthodontic treatment with an attached treatment plan showing the limited phase of treatment. In this case, prior authorization must be submitted for comprehensive orthodontic treatment with an attached treatment plan showing the interceptive treatment phase. The maximum number of treatment visits to be considered in each prior authorization is 12.
The surgical consultation, treatment plan and surgical case approval must be included with the request for prior authorization of the orthodontic services.
Addendum C: Dental Forms
Addendum D: Fully Integrated Dual-Eligible Special Needs Plans
Note: A Provider may charge a Member for services not covered by WellCare only when both parties have agreed before the service is provided that the Member is treated as a private payer. The Provider must obtain the Member's written consent that he or she will be financially responsible for the uncovered service and that consent must be signed and dated on or before the date of service. Because we have separate contracts with each entity, we must create a claim for each of them.
This has confused some providers and we have added the following statement to the EOP (highlighted in yellow below).