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Provider's reimbursement and payment methodology, by major service category, is described herein. (Please note that the Proxy Reimbursement Grid will change over the plan year. Check back often to make sure you have the most up-to-date version. )
CLAIMS SUBMISSION PROCEDURES
- You must submit a claim to WellCare PFFS for an Original Medicare-covered service within the same time frame you would have to submit under Original Medicare*. Failure to be timely with claim submissions may result in non-payment. 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.
- Prompt Payment —WellCare PFFS will process and pay clean claims within 30 days of 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. A clean claim includes the minimum information necessary to adjudicate a claim, not to exceed the information required by Original Medicare. WellCare PFFS will process all non-clean claims and notify providers of the determination within 45 days of receiving such claims.
- Submit claims using the standard CMS-1500, CMS-1450 (UB-04), or the appropriate electronic filing format. We encourage you to submit claims electronically. These claims should process faster and with minimal chance of error. Of course, accurate claims data are crucial.
- Use the same coding rules and billing guidelines as Original Medicare, including Medicare CPT Codes, HCPCS codes and defined modifiers. Bill diagnosis codes to the highest level of specificity.
- Pay special attention to accuracy of the following on your claims:
- National Provider Identifier. (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.)
- The member’s ID number.
- The member’s name exactly as indicated on his or her ID card.
- The provider and/or practice entity names and Tax Identification Number (TIN) that match those on the W-9.
- Date(s) of service.
- For providers that are paid based upon interim rates, include with your claim a copy of your current interim rate letter if the interim rate has changed since your previous claim submission.
- Coordination of Benefits: All Medicare secondary payer rules apply. These rules can be found in the Medicare Secondary Payer Manual located at www.cms.hhs.gov/Manuals/IOM/list.asp. Providers should identify primary coverage and provide information to WellCare PFFS at the time of billing.
*Timely Filing Requirements:
- See new information at top of page.
To submit a claim electronically:
To register for electronic claims submission through use of clearinghouses, visit the Emdeon Business Services Web site at http://emdeon.com.
WellCare PFFS EDI Payer ID number is 77072. (In some markets, WellCare has multiple product lines and it is important to use this number for PFFS claims.)
Emdeon Support ..............................................................................1-800-845-6592
Paper claims may be submitted to:
Medicare-Covered 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
PROVIDER PAYMENT DISPUTE RESOLUTION PROCESS
If you believe that the payment amount you received for a service is less than the amount indicated in our terms and conditions of payment, you have the right to dispute the payment amount by following our dispute resolution process.
To file a payment dispute with WellCare PFFS, send the “Provider Claim Payment Resolution Process Form,” a copy of the claim being disputed and all supporting documentation by mail or fax to:
WellCare Health Plans, Inc.
Attn: Provider Claim Dispute
P.O. Box4438
Scranton, PA 18505
Fax: 1-866-473-9122
Additionally, please provide appropriate documentation to support your payment dispute, e.g., the remit and any information that Original Medicare would pay differently for the service on the claim. Claims must be disputed within 120 days from the date payment is initially received by the provider.
We will review your dispute and respond to you within 30 days from the time the provider payment dispute is first received by WellCare PFFS. If we agree with your payment dispute, then we will pay you the additional amount with any interest that is due. We will inform you in writing if your payment dispute is denied.
After completing WellCare PFFS dispute resolution process, if you believe that we have reached an incorrect decision regarding your payment dispute, you may file a request for review of this determination with an independent entity contracted by CMS. To file a request for review of a payment dispute with the independent entity, you may contact the entity directly at the contact options listed below.
Deemed and non-contracted providers should request an independent Payment Dispute Decision (PDD) from First Coast Service Options, Inc. (FCSO) within 180 days of the written notice from WellCare PFFS about the initial claims dispute. The request must be in writing and should be made on a standard PDD form available at the FCSO’s Web site, www.fcso.com. FCSO has established the following options for receipt of payment dispute decision requests:
1. E-mail. If the submission and associated documents do not contain any personally identifiable health information (PHI) or any PHI has been redacted, the payment dispute decision request can be submitted via e-mail to a dedicated box at IREPFFS@FCSO.com. Otherwise, FCSO can receive payment dispute decision requests (including associated documents such as claims forms that may contain PHI) via fax or mail.
2. Fax. 1-904-361-0551. Fax number has been established to receive electronic requests for payment dispute decisions.
3. Mail. Providers can mail hard copy requests for payment dispute adjudication to the following address:
First Coast Service Options, Inc.
PFFS Payment Disputes
P.O. Box44017
Jacksonville, Florida 32231-4017
Providers with questions regarding the adjudication process or individual disputes being reviewed by the independent review entity (IRE) can contact FCSO at 1-904-791-6430.
Texas Dual-Eligible PFFS Member Expenses — Coordination of Benefits
WellCare is aware of questions regarding cost-sharing coverage for Medicare/Medicaid dual-eligible members, so we have been engaged in discussions with the state of Texas and would like to share information on how to file provider claims.
For WellCare PFFS claims with a service date in 2007:
Questions about these claims should be directed to the TMHP Contact Center at 1-800-925-9126.
For WellCare PFFS claims with a service date between January 1, 2008 and January 3, 2010:
Beginning January 4, 2010, TMHP will begin processing claims with dates of service on or after January 1, 2008, for coinsurance and/or deductibles for dual-eligible beneficiaries enrolled in WellCare PFFS plans, since they are not contracted with HHSC.
Providers must submit claims for coinsurance and deductibles using the revised Medicare Remittance Advice Notice (MRAN)/MAP templates. Providers must attach a copy of the completed CMS-1500 paper claim form to the completed MRAN form. The forms must be legible and identify only one client per page. Providers are not to submit handwritten MRAN forms. Claims that do not meet these standards will not be processed and will be returned to the provider.
The new templates and instructions are available on the TMHP Web site at www.tmhp.com, on the Medicare/Medicaid Dual Eligibility Claims page, and will be published in the 2010 March/April Texas Medical Bulletin, No. 228.
Claims with dates of service on or after January 1, 2008 through January 3, 2010, must be submitted to TMHP from January 4, 2010 through March 31, 2010. Claims submitted may initially be denied for filing deadlines; however, TMHP will reprocess these claims. No action on the part of the provider is necessary.
TMHP will not reprocess the following claims:
- Dates of service on or after January 4, 2010.
- Dates of services January 1, 2008 through January 3, 2010 submitted after March 31, 2010.
- Denied claims for reasons other than filing deadline.
Claims submitted after January 4, 2010 will follow the normal Medicare submission process which is 95 days after the disposition date from WellCare, original filing deadlines must be met.
For more information, call the TMHP Contact Center at 1-800-925-9126.
For WellCare PFFS claims with a service date in 2009:
WellCare discontinued PFFS plans for Texas residents as of January 1, 2009, but Texas providers who meet the requirements of and agree to the WellCare PFFS Terms and Conditions of Payment (www.wellcarepffs.com/provider/terms) can continue to see patients that may be from another service area. Follow the direction above for these claims.
