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 hope you find this a useful resource, and the areas highlighted to the right are sections of the manual that directly address our common goal of delivering quality care.
Appeals and Grievances
See your provider agreement or contact your WellCare Provider Relations representative for clarification on any of the following. WellCare's diversity and language skills - WellCare employs a diverse, talented staff to work at all levels of the organization. Providers may request a copy of the criteria used to make a special determination of medical need by calling the Provider Services Department listed in the Quick Reference Guide on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid.
Transplant procedures and related services must be approved by WellCare prior to the transplant, regardless of the Member's age. Initial request: A letter will be mailed to the Provider requesting that records be provided within 30 days of the date of the letter. Medical appropriateness and necessity, including that of the medical environment, must be clearly substantiated in the Member's medical record.
In the event of a determination of unwanted benefits, WellCare will notify the member in writing of the determination of unwanted benefits. To seriously endanger the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child). After the credentialing process is completed, a timely notification of the credentialing decision is sent to the provider.
A Provider may not submit a complaint on behalf of the Member without the Member's written permission. Upon receipt of the complaint, a written resolution will be sent to the member within 30 calendar days from the date the complaint was received by WellCare. Unless an extension is elected, WellCare will send a closure letter upon resolution of the member's complaint.
Compliance
Protection from retaliation for employees and subcontractors who report suspected fraud, waste and abuse; and. Providers, including Provider employees and/or Provider subcontractors, must report to WellCare any fraud, waste or abuse, misconduct or suspected criminal acts by. Details of the Corporate Ethics and Compliance Program can be found on WellCare's website at www.wellcare.com/Kentucky/Corporate/Compliance.
WellCare is committed to preventing, detecting and reporting healthcare fraud and abuse in accordance with applicable federal and state statutory, regulatory and contractual requirements. WellCare has developed an aggressive, proactive fraud and abuse program designed to collect, analyze and evaluate data to identify suspected fraud and abuse. Providers who engage in fraud 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 Provider, loss of license and/or civil and/or or criminal prosecution, fines and other penalties.
To meet federal regulation standards specific to Fraud, Waste and Abuse Providers and their employees must complete an annual FWA training program. To report suspected fraud and abuse, please refer to the Quick Reference Guide on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid or call WellCare's toll-free, confidential compliance hotline. Details of the Corporate Ethics and Compliance Program and how to contact the WellCare Fraud Hotline can be found on the WellCare website at www.wellcare.com/Kentucky/Corporate/Compliance.
The practice must ensure that there is a procedure or process in place for maintaining the confidentiality of Members' medical records and other PHI and that the practice follows those procedures and/or obtains appropriate authorization from Members to release information or records where required by applicable state. and federal law. HIPAA provides for the release of member medical records to WellCare for payment and quality purposes, and/or health plan operations. All personal and/or protected health information as defined under the federal HIPAA privacy regulations, and/or other state or federal laws;.
Refer to Section 3: Quality Improvement for guidance on responding to WellCare's requests for member health records for purposes of treatment, payment, and health care activities. WellCare's Customer Service Department using the toll-free phone number found on the Member's ID card. Providers may contact the WellCare Customer Service Department by referring to the Quick Reference Guide on the WellCare website at.
Delegated Entities
Behavioral Health
Pharmacy
See the Quick Reference Guide on the WellCare website at www.wellcare.com/en/Kentucky/Providers/Medicaid; and. For contact information, see the Quick Reference Guide on the WellCare website at www.wellcare.com/en/Kentucky/Providers/Medicaid. See the Quick Reference Guide on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid.
Refer to the Quick Reference Guide on WellCare's website at www.wellcare.com/Kentucky/Providers/Medicaid for contact information. For contact information, see the Quick Reference Guide on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid. The DDE tool can be found on the Provider Portal at www.wellcare.com/Kentucky/Providers.
For more information about free DDE options, see the Provider Resource Guide on the WellCare website at For a complete list, see the PDL on the WellCare website at www.wellcare.com/Kentucky/Providers/Medicaid/Pharmacy.
Definitions and Abbreviations
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 Services Act (42 U.S.C a) and the regulations promulgated hereunder. Co-surgeon” means one of several surgeons who work together as primary surgeons and perform separate parts of a surgical procedure. EPSDT” means Early and Periodic Screening, Diagnosis and Treatment Program that provides medically necessary health care, diagnostic services, preventive services, rehabilitation services, treatment and other measures described in 42 USC Section 1396d(a) to all Members under 21 years of age.
EPSDT Special Services" means medically necessary health care, diagnostic services, treatment, and other measures described in Section 1905(a) of the Social Security Act to correct or alleviate defects and physical and mental diseases and conditions identified by EPSDT screening services, whether or not are such services covered by the State Medicaid plan. Emergency Services" or "Emergency Care" means covered inpatient and outpatient services that are as follows: (1) provided by a provider qualified to provide those services; and (2) necessary to evaluate or stabilize an acute medical condition. Meeting Data” means meeting information, data and reports for Covered Services provided to a Member who meets the requirements for Clean Claims.
Kentucky Contract" means the Medicaid Managed Care Contract between the Commonwealth of Kentucky, Finance and Administration Cabinet and WellCare of Kentucky, Inc., and any amendments, including corrections or modifications thereto. Member" means an individual who is properly enrolled in a benefit plan and is entitled to receive Covered Services at the time such Services are provided. Member Expenses" means copayments, coinsurance, deductibles or other cost sharing amounts, if any, that a Member is required to pay for Covered Services under a Benefit Plan.
Schedule of Periodicity” means the schedule that defines the age-appropriate services and time frames for examinations under the Early and Regular Screening, Diagnosis and Treatment (EPSDT) program. Prior Authorization” means the process of obtaining authorization prior to a scheduled hospital admission or outpatient procedure or service. Provider” means any person (including physicians or other health care professionals), partnership, professional association, corporation, foundation, hospital, or institution certified, licensed, or registered in the State of Kentucky to provide health care services that contracts with WellCare to provide health care care. member service.
Screening means the assessment of a recipient's health and health-related conditions by a healthcare professional to determine whether further diagnosis or treatment is necessary. Service Location” means any location where a Member may obtain Covered Services from a Network Provider. WellCare Companion Guide” means the transaction guide that sets forth the data requirements and electronic transaction requirements for Clean Claims and encounter data submitted to WellCare or its affiliates, as amended from time to time.
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