INTRODUCTION

Reimbursement for dental, vision and hearing providers for non-Medicare-covered services that are covered by WellCare PFFS is based on WellCare PFFS vendors’ usual and customary fees. For information on how to contact these vendors, please see the member’s dental/hearing/vision ID card or the WellCare PFFS Quick Reference Contact Guide .

• PFFS plans are not HMOs or PPOs.
   
• Referrals or preauthorizations of health care services are not required for medically necessary services.
   
• Provider reimbursement is based on published Original Medicare rates, reimbursement guidelines and methodologies, less the member’s cost-sharing amounts. Medicare Local Coverage Determinations apply.
   
• WellCare PFFS directly reimburses physicians and other health care professionals for non-dual-eligible members. Reimbursement for dual eligible members will be paid first by Medicare through WellCare PFFS. The difference will be paid by Medicaid, up to the state payment limit.
   
• Physicians, hospitals and other providers who render services to WellCare PFFS members must adhere to all industry standards and state and federal requirements.
   
• Since WellCare PFFS plans are Medicare Advantage (MA) plans, applicable Medicare and/or other federal health care program laws, regulations and program instructions must be followed, including but not limited to, the standards for confidentiality and patients’ rights outlined in the 1997 Consumer Bill of Rights and Responsibilities and all relevant HIPAA regulations.

PROVIDER ELIGIBILITY, PARTICIPATION AND DEEMING

Provider Eligibility

Physicians, hospitals or other health care providers may choose to provide services to a WellCare PFFS member if they:

• Have reasonable access to WellCare’s Terms and Conditions;
   
• Agree to accept WellCare’s Terms and Conditions and
   
• Meet the following requirements:
   
  • Are licensed or certified by the state and are acting within the scope of that license or certification;
     
  • Have a Medicare billing number or are eligible to obtain one. Institutional providers treating PFFS enrollees, such as hospitals and skilled nursing facilities, must be certified to treat Medicare beneficiaries (if serving a dual-eligible PFFS member, the physician or provider must also be eligible for Medicaid payment);
     
  • Have not opted out of Medicare participation;
     
  • Are not sanctioned;
     
  • Comply with all applicable Medicare and other applicable federal health care program laws, regulations and program instructions, including laws protecting patient privacy rights and HIPAA regulations that apply to the covered services furnished to members and
     
  • Are not federal health care providers, such as a Veterans Administration provider. Under general regulations, these providers are not eligible for reimbursement under a PFFS plan except when providing emergency care to non-veterans.

If these conditions are met, a physician or provider may provide covered services to a WellCare PFFS member and will be reimbursed in accordance with WellCare’s PFFS Proxy Payment Grid .  If the physician or provider has any questions, he or she may contact the Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern.

Provider Participation

Before providing covered services, the physician, hospital or other health care provider must:

• Have knowledge that the patient is enrolled as a member in a WellCare PFFS plan by:
   
  • Requesting that the member present a WellCare PFFS ID card and/or
     
  • Further validate eligibility by contacting the Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern. Registered Web site users click here.  
     
• Agree to render services to a WellCare PFFS member;
   
• Agree to bill WellCare PFFS for reimbursement for Medicare-covered services;
   
• Agree to bill WellCare PFFS dental, vision and hearing vendors for non-Medicare-covered services that are covered by WellCare PFFS. (For information on how to contact these vendors, please see the member’s dental/hearing/vision ID card or the WellCare PFFS Quick Reference Contact Guide and
   
• Agree to only collect from the member the appropriate WellCare co-payments, coinsurance and amount for non-covered services described in these Terms and Conditions and agree not to balance-bill members.

Hospitals and other facilities must also agree to comply with Medicare regulatory requirements including, but not limited to, the revised “Important Message from Medicare (CMS-R-193),” “Detailed Notice of Discharge (CMS 10066)” and “Notice of Medicare Non-Coverage (NOMNC) (CMS-10095)” notices as applicable. These notices can be accessed via the Centers for Medicare & Medicaid Services (CMS) Web site at www.cms.hhs.gov.

The physician or provider must provide information regarding treatment options in a culturally competent manner, including the option of no treatment, and ensure that members have access to communicate with the provider.

If the physician or provider has any questions, he or she may contact the Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern.

Deeming Process

A provider is deemed if:

• They meet the requirements listed under “Provider Eligibility” and “Provider Participation” above and
   
• The service(s) provided is/are covered by the member’s WellCare PFFS plan.

In addition, if a member enters a hospital for non-emergency care, advises the hospital that he or she is a member of a WellCare PFFS plan, and presents his or her WellCare PFFS ID card, all providers that contract with this hospital, or are employed by this hospital, are considered deemed as soon as they provide services.

If you DO NOT wish to accept WellCare’s Terms and Conditions of Payment, then you should not furnish services to a WellCare PFFS member, except for emergency services. If you nonetheless do furnish nonemergency services, you will be subject to these Terms and Conditions whether you wish to agree to them or not. Providers furnishing emergency services will be treated as non-contract providers and reimbursed the payment amounts they would have received under Original Medicare. You can only collect from the member the appropriate WellCare co-payments or coinsurance described in these

PROVIDER REIMBURSEMENT

Provider Reimbursement for WellCare PFFS Plans

In general, WellCare PFFS will reimburse physicians and providers for covered services according to the Original Medicare rates, reimbursement guidelines and methodologies, less the member’s cost-sharing amounts. In addition, Medicare Local Coverage Determinations will apply. Please review payment methodology outlined by service type in the Proxy Payment Grid .

By enrolling in a WellCare PFFS plan, Medicare beneficiaries may have benefits such as health club membership, hearing, vision and dental. To view products and the plan overviews, please review Our Plans. Reimbursement for dental, vision and hearing providers for non-Medicare-covered services that are covered by WellCare PFFS is based on WellCare PFFS vendors’ usual and customary fees. For information on how to contact these vendors, please see the member’s dental/hearing/vision ID card or the WellCare PFFS Quick Reference Contact Guide .

When WellCare PFFS pays for medically necessary covered services rendered, the member’s applicable cost sharing is deducted from the provider payment. All physicians and providers who render services to WellCare PFFS members must accept the WellCare PFFS plan’s payment, plus the member’s applicable cost sharing as payment in full. Providers may not balance-bill the member for any greater amount on covered services.

Providers who have submitted claims to WellCare PFFS may register to view claims status online at the Claim & Reimbursement section.

Medically Necessary Services

CMS defines medically necessary services as services or supplies that:

• Are proper and needed for the diagnosis or treatment of a medical condition;
   
• Are provided for the diagnosis, direct care and treatment of a medical condition;
   
• Meet the standards of good medical practice in the local area and
   
• Are not mainly for the convenience of the member or the provider.

WellCare PFFS plans are not required to pay for services that are not medically necessary under Medicare. WellCare PFFS plans may include additional benefits, and in those cases, it will pay for services that are covered by the WellCare PFFS plan and are medically necessary. If a member obtains a service that is not covered by their WellCare PFFS plan, the member is responsible for the entire cost of that service. If a member is not sure whether a service will be covered by his or her WellCare PFFS plan, the member or provider then has the right to contact the plan to ask for an advance coverage decision.

To view a complete list of covered services and cost-sharing amounts under WellCare PFFS, please view Our Plans or contact our Provider Service Center at 1-866-235-2770

(TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern. WellCare PFFS plans follow Medicare coverage guidelines to determine benefits, unless otherwise specified. Be sure to have the member’ s ID number when you call. After collecting cost-sharing from the member, the provider should bill WellCare PFFS for covered services.  

WellCare PFFS plans do not have any prior authorization or prior notification requirements.

Member Plan Benefits as It Applies to Provider Reimbursement

By enrolling in a WellCare PFFS plan, Medicare beneficiaries may have benefits such as health club membership, hearing, vision and dental. To view products and the plan overviews, please select the option “ Our Plans or contact our Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern . WellCare PFFS plans follow Medicare coverage guidelines to determine benefits, unless otherwise specified. WellCare PFFS plans do not have any prior authorization or prior notification requirements for medically necessary services. Payment of cost-sharing amounts is the responsibility of the member. Deemed providers should collect the applicable cost-sharing from the member at the time of the service. After collecting cost-sharing from the member, the provider should bill WellCare PFFS for covered services.

Services not covered by Medicare are not covered by WellCare PFFS plans unless specified in the “Terms and Conditions of Payment,” “Summary of Benefits” or “Evidence of Coverage” documents.

A provider may collect only applicable plan co-payment or coinsurance amounts from WellCare PFFS members and may not otherwise charge or bill the members for benefits covered under Original Medicare. Balance billing is prohibited by deemed providers who furnish services to WellCare PFFS members.

If you have any questions about whether a service is covered under a WellCare PFFS plan or would like to obtain a copy of our “Summary of Benefits” or “Evidence of Coverage” documents, contact the Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern.

Retrospective Review

Retrospective review is performed when a service has been provided and the claim has been adjudicated. Retrospective review decisions resulting in nonpayment will not be reversed unless updated or additional information is received from the provider.

Medical Records

Medical records are an important part of treating WellCare PFFS members and ensuring compliance standards are met. Deemed providers shall maintain timely and accurate medical, financial and administrative records related to services rendered by the provider to WellCare PFFS members. Unless a longer time period is required by applicable statutes or regulations, the provider shall maintain such records for at least 10 years from the date of service. Deemed providers agree that WellCare, the Department of Health and Human Services (HHS), the Comptroller General, or their designees may access any books, contracts, medical records, patient care documentation and other records maintained by the provider pertaining to services rendered to Medicare beneficiaries enrolled in a Medicare Advantage plan, consistent with federal and state privacy laws. Such records may be used for activities in the following situations: CMS and WellCare audits of risk adjustment data; WellCare determinations of whether services are covered under the plan, are reasonable and medically necessary, and whether the plan was billed correctly for the service; and in order to make advance coverage determinations. WellCare will not use medical record reviews to create artificial barriers that would delay payments to providers. Both voluntary and mandatory provision of medical records must be consistent with HIPAA privacy law requirements.

Records will be requested when needed and/or required by CMS or WellCare. When these occasions arise, a WellCare representative will work with the provider and their office to ensure that the process is as smooth as possible.

Advance Coverage Determination

WellCare PFFS plans do not have any prior authorization or prior notification requirements for medically necessary services. However, providers have the right to obtain a written advance coverage determination (also known as an organization determination) from WellCare PFFS before furnishing a service in order to confirm whether that service will be covered by WellCare PFFS. To obtain an advance coverage determination, use the Medicare Coverage Determination Request Form . WellCare PFFS will make a decision and notify you no later than 14 days after WellCare PFFS receives the request. In cases where you believe that waiting for a decision in the 14-day time frame could place the member’s life, health or ability to regain maximum function in serious jeopardy, you can request an expedited determination. To obtain an expedited determination, use the Medicare Coverage Determination Request Form . In expedited determinations, WellCare PFFS will make a decision and notify you within 72 hours after WellCare PFFS receives the request.

In the absence of an advance coverage determination, WellCare PFFS can retroactively deny payment for a service furnished to a member if we determine that the service was not covered by our plan or was not medically necessary. However, you have the right to dispute our decision.

PROVIDER BILLING PROCEDURES

Claims Submission Procedures

WellCare PFFS plans follow Medicare’s prompt payment requirements for all clean claims. CMS requires 95% of clean claims be paid within thirty (30) days from receipt. If a clean claim is not paid within the 30-day time frame, WellCare PFFS will pay interest on the claim according to Medicare guidelines. Clean claims as defined by Medicare are those claims that have no defect, impropriety, lack of any required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment and otherwise conforms to the clean claim requirements for equivalent claims under Original Medicare. The criteria for Original Medicare submission of claims can be found in Section 70 of Chapter 1 of the Medicare Claims Processing Manual located at www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.

Physicians and providers should submit claims using the same coding rules as Original Medicare, including usage of Medicare CPT Codes and defined modifiers, and diagnosis codes to the highest specificity.

Physicians and providers understand that they are subject to laws applicable to persons or entities receiving federal funds, and must notify all subcontractors that they are also subject to these laws. All Medicare secondary payer rules apply. Providers should obtain information on primary payer coverage and bill accordingly. Failure to be timely with claim submissions may result in nonpayment.

If you have any questions about claims submission, contact the Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern.

Claim Submission Requirements

Timely Filing Requirements:

• For services received between October 1, 2006, and September 30, 2007, claims must be submitted by December 31, 2008.
   
• For services received between October 1, 2007, and September 30, 2008, claims must be submitted by December 31, 2009.

To submit a claim electronically, contact:

ACS EDI Gateway, Inc., between 8am and 5pm Eastern at 1-800-952-0495, or register online at http://edidirect.acs-inc.com/edidirect.

WellCare’s PFFS EDI Payer ID number is 77072.

Paper claims may be submitted to:

Medical Claims:

WellCare Health Plans, Inc.
P.O. Box 4438
Scranton , PA 18505

Non-Medicare-Covered Claims:

Dental

Doral National Medicare Plan
P.O. Box 45
Grafton , WI 53024

Vision

Advantica EyeCare
P.O. Box 6546
Ellicott City , MD 21042

Hearing

HearUSA Hearing Care Network
P.O. Box 220807
West Palm Beach , FL 33422

Hold Harmless

Pursuant to this agreement, physicians, hospitals and other providers who render services to WellCare PFFS members agree that in no event, including but not limited to, nonpayment by WellCare or an intermediary, insolvency of WellCare or an intermediary, or breach by WellCare of this agreement, will a provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any member or person (other than WellCare or an intermediary) acting on behalf of the member, for health services provided.

1. The above provision does not prohibit from collecting co-payments, coinsurance or fees for services not covered under the member’s benefit contract and delivered on a fee-for-service basis to the member.
    
2.  This provision does not prohibit the physician or provider and a member from agreeing to perform noncovered services solely at the expense of the member, as long as the physician or provider has clearly informed the member that WellCare PFFS may not cover, or continue to cover, a specific service or services.
    
3. Covered benefits for members confined in an inpatient facility on the date of insolvency or other cessation of operations will continue until their continued confinement in an inpatient facility is no longer medically necessary.

Provider Practice Changes

Providers should contact the Provider Service Center if any demographic or billing changes are planned within the next thirty (30) days. To ensure continuity of service, prior notice to WellCare PFFS is needed for any of the following changes in your practice:

• 1099 mailing address
• Tax identification number or entity affiliation (W-9 required)
• Group name or affiliation
• Physical or billing address
• Telephone and fax number
• CMS payment rate

Also, physicians, hospitals and other providers are asked to notify WellCare PFFS in the event of a Medicare provider number change (i.e., an acute care hospital changes to a critical access hospital; a family practice clinic changes to a rural health clinic, etc.) that results in a change in reimbursement.

To notify WellCare PFFS of any of these types of changes:

• Calling: Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern;
• Faxing: 1-866-354-8718 or
• Writing to:

WellCare Health Plans, Inc.
PFFS
P.O. Box 31405
Tampa , FL 33631-3405

NPI

All paper and electronic claims must have only an NPI in the required primary and secondary provider fields. Failure to include an NPI will cause the claim to reject.

Visit the CMS NPI Web page at www.cms.hhs.gov/NationalProvidentStand/06_implementation.asp for more details.

PROVIDER CLAIM PAYMENT DISPUTE RESOLUTION AND APPEALS

Physicians and/or other health care professionals have the right to dispute a claims payment with WellCare Health Plans, Inc. If a provider disagrees with the WellCare payment rate and has information that Original Medicare would pay differently for a service, such documentation may be submitted for review and appropriate adjustment to payment. See “Provider Claim Payment Dispute Resolution Process” below. WellCare reserves the right to retrospectively review claims for claims payment accuracy based on the information submitted. After completing this process, if you believe we have reached an incorrect decision, you may file a complaint with CMS. To file a complaint with CMS, send a written complaint to CMS.

Physicians, hospitals and other providers who render services to WellCare PFFS members agree to abide by the WellCare appeal procedures for medical necessity and/or benefits. See “Provider Appeal for Medical Necessity and/or Benefits Process” below.

WellCare PFFS plans’ claim dispute and appeals procedures and appropriate forms can be found at http://www.wellcarepffs.com/provider/forms .

Provider Claim Payment Dispute Resolution Process

A provider has one (1) year from the date of the initial determination notice to submit a dispute.

• The provider should submit his or her request of claim dispute using the Provider Claim Payment Resolution Process Form   
   
• The Provider Claim Payment Resolution Process Form , a copy of claim being disputed and all supporting documentation should be mailed or faxed to:

WellCare Health Plans, Inc.
P.O. Box 4438
Scranton , PA 18505

or

1-866-473-9122

• Provider claim disputes will be resolved within sixty (60) days of initial receipt of the dispute by WellCare.
   
• Contact our Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern for questions related to claim payment dispute resolution submission or status.

Provider Appeal for Medical Necessity and/or Benefits Process

A provider has ninety (90) days from the date of the initial determination to submit a medical necessity and/or benefit appeal.

• The provider should submit his or her request of appeal using the Provider PFFS Appeal Form  
   
• The Provider PFFS Appeal Form , all additional, appropriate appeal forms and medical records should be mailed or faxed to:

WellCare Health Plans, Inc.
P.O. Box 31368
Tampa , FL 33631

or

1-866-201-0657

• Provider appeals will be resolved, in writing, within sixty (60) days of initial receipt of the appeal by WellCare.
   
• Contact our Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern for questions related to appeal submission or status.

Providing Members with Notice of Their Appeals Rights—Requirements for Hospitals, SNFs, CORFs and HHAs

Hospitals must notify Medicare beneficiaries who are hospital inpatients about their discharge appeal rights by complying with the requirements for providing the Important Message from Medicare (IM), including the time frames for delivery. For copies of the notice and additional information regarding this requirement, go to: www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp

Skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities must notify Medicare beneficiaries about their right to appeal a termination of services decision by complying with the requirements for providing Notice of Medicare Non-Coverage (NOMNC), including the time frames for delivery. For copies of the notice and the notice instructions, go to:

www.cms.hhs.gov/MMCAG/Downloads/NOMNCForm.pdf  and

www.cms.hhs.gov/MMCAG/Downloads/NOMNCInstructions.pdf .

WellCare PFFS will provide members with a detailed explanation if a member notifies the Quality Improvement Organization (QIO) that the member wishes to appeal a decision regarding a hospital discharge or termination of home health agency, comprehensive outpatient rehabilitation facility or skilled nursing facility services within the time frames specified by law.

MEMBER INFORMATION FOR PROVIDERS

Member Coverage Determination, Appeal and Grievance Rights

Members have the right to request a coverage determination for health care benefits they believe a WellCare PFFS plan should cover. Members also have the right to request a coverage determination, or to file an exception request for a prescription drug they think should be covered by a WellCare PFFS plan as a result of this coverage determination.

Members also have the right to an appeal (redetermination) if the WellCare PFFS plan denies coverage or payment for health care services they think should be covered. If the decision of the appeal (redetermination) is to continue the denial of coverage or payment, then members have the right to file a request for reconsideration with Maximus Federal Services, a company contracted by CMS to review managed care organization denials.

Members have the right to file a grievance when dissatisfied with a WellCare PFFS plan, a provider or health care services received.

Members can contact WellCare PFFS with questions about coverage determinations, exception requests, appeals or grievances, by contacting Customer Service at 1-866-238-9898 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 8am to 2am Eastern.

Any party to an action appropriate for appeal, including a reopened and revised determination, to include a member, a member’s authorized representative, or a provider, may request that a determination be reconsidered. Providers do not have appeal rights through the member appeal process.

The member, member’s representative or any provider acting on the member’s behalf may file for an expedited, standard pre-service or retrospective appeal determination. The request must come from the physician, not from office staff. WellCare’s PFFS plan will not take or threaten to take any punitive action against any provider acting on behalf, or in support of, a member requesting an appeal or an expedited appeal. WellCare PFFS plans are health plans that are approved by and contracted with CMS. The availability of coverage beyond the end of the current contract year is not guaranteed. Benefits may vary by plan and by county/parish.