|  |
Effective July 1, 2007, Medicare will reject any CMS-1500 (12-90) version forms received. Claims received on the previous forms will be returned to the submitters for resubmission on the 08-05 version of the form. NPI-Don't forget to include your NPI number on every claim submitted. Failure to do so will result in the claim being rejected. Visit the CMS NPI web page at www.cms.hhs.gov/NationalProvidentStand/06_implementation.asp for more details. |
WellCare, a private insurance company under contract with the Centers for Medicare and Medicaid Services (CMS), offers Private Fee-for-Service (PFFS) plans. WellCare is committed to meeting the needs of consumer demand for affordable health care coverage with direct access to physicians and hospitals. To meet this need, WellCare PFFS wants to make our reimbursement methodologies and guidelines as easily accessible as possible, please find them below.
Reimbursement information - 2008 Proxy Payment Grid
Provider's reimbursement and payment methodology, by major service category, is described herein. (Please note that this Proxy Payment Grid will be updated regularly. Check back often to make sure you have the most up-to-date version.)
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 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