1. INTRODUCTION

WellCare Concert, WellCare Melody, WellCare Melody-Plus, WellCare Prelude, WellCare Quartet, WellCare Serenade, WellCare Sonata and WellCare Sonata-Plus are Medicare Advantage Private Fee-for-Service (PFFS) plans offered by WellCare Health Plans, Inc. WellCare PFFS allows members to use any provider, such as a physician, health professional, hospital or other Medicare provider in the United States that agrees to treat the member after having the opportunity to review these terms and conditions of payment, as long as the provider is eligible to provide health care services under Medicare Part A and Part B (also known as ‘Original Medicare’) or eligible to be paid by WellCare PFFS for benefits that are not covered under Original Medicare.

The law provides that if you have an opportunity to review these terms and conditions of payment and you treat a WellCare PFFS member, you will be “deemed” to have a contract with us. Section 2 explains how the deeming process works. The rest of this document contains the contract that the law allows us to deem to hold between you, the provider, and WellCare PFFS. Any provider in the United States that meets the deeming criteria in Section 2 becomes deemed to have a contract with WellCare PFFS for the services furnished to the member when the deeming conditions are met. No prior authorization, prior notification or referral is required as a condition of coverage when medically necessary, plan-covered services are furnished to a member. However, a member or provider may request an advance coverage determination before a service is provided in order to confirm that the service is medically necessary and will be covered by the plan. Note that the terms prior authorization, prior notification and advance coverage determination have different meanings. Prior authorization and prior notification rules are described in Section 4, and advance coverage determination is described in Section 7.

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2. WHEN A PROVIDER IS DEEMED TO ACCEPT WELLCARE PFFS TERMS AND CONDITIONS OF PAYMENT

A provider is considered by law to be deemed to have a contract with WellCare PFFS when all of the following three criteria are met:

1. The provider is aware, in advance of furnishing health care services, that the patient is a member of WellCare PFFS. All of our members receive a member ID card that includes the WellCare logo that clearly identifies them as PFFS members. The provider may further validate eligibility by calling our Provider Service Center at 1-866-235-2770. Registered Web site users may visit www.wellcarepffs.com and select “Eligibility & Benefits” to validate eligibility. Specifically, you can identify a WellCare PFFS member by looking at their member ID card on which their member ID should begin with the letter “F”. If it contains only numerals, and no “F” prefix, then it is not a WellCare PFFS member and could be with WellCare’s coordinated care plans or one of WellCare’s Medicaid plans.
    
2. The provider either has a copy of, or has reasonable access to, our terms and conditions of payment (this document). The terms and conditions are available on our Web site at www.wellcarepffs.com/provider/terms. The terms and conditions may also be obtained by calling our Provider Service Center at 1-866-235-2770.
    
3. The provider furnishes covered services to a WellCare PFFS member.

If all of these conditions are met, the provider is deemed to have agreed to WellCare PFFS terms and conditions of payment for that member specific to that visit. Note: You, the provider, can decide whether or not to accept WellCare PFFS term and conditions of payment each time you see a WellCare PFFS member. A decision to treat one plan member does not obligate you to treat other WellCare PFFS members, nor does it obligate you to accept the same member for treatment at a subsequent visit.

For example: If a WellCare PFFS member shows you an enrollment card identifying him/ her as a member of WellCare PFFS and you provide services to that member, you will be considered a deemed provider. Therefore, it is your responsibility to obtain and review the terms and conditions of payment prior to providing services, except in the case of emergency services (see below).

If you DO NOT wish to accept WellCare PFFS 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 non-emergency 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 paid at the payment amounts they would have received under Original Medicare.

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3 . PROVIDER QUALIFICATIONS AND REQUIREMENTS

In order to be paid by WellCare PFFS for services provided to one of our members, you must:

• Have a National Provider Identifier in order to submit electronic transactions to WellCare PFFS, in accordance with HIPAA requirements.
• Submit non-electronic transactions using the standard CMS-1500 or CMS-1450 (UB-04), paying special attention to your National Provider Identifier (NPI), the member’s name exactly as indicated on their ID card and member ID number. (See Section 5 for specific requirements.)
• Furnish services to a WellCare PFFS member within the scope of your licensure or certification.
• Provide only services that are covered by our plan and that are medically necessary by Medicare definitions.
• Meet applicable Medicare certification requirements (e.g., if you are an institutional provider such as a hospital or skilled nursing facility).
• Not have opted out of participation in the Medicare program under §1802(b) of the Social Security Act, unless providing emergency or urgently needed services.
• Not be on the HHS Office of Inspectors General excluded and sanctioned provider lists.
• Not be a federal health care provider, such as a Veterans’ Administration provider, except when providing emergency care.
• 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 that apply to covered services furnished to members.
• Agree to cooperate with WellCare PFFS to resolve any member grievance involving the provider within the time frame required under federal law.
  For providers who are hospitals, home health agencies, skilled nursing facilities or comprehensive outpatient rehabilitation facilities, provide applicable beneficiary appeals notices. (See Section 10 for specific requirements.)
• Not charge the member in excess of cost-sharing under any condition, including in the event of plan bankruptcy.
• 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 or request a copy by calling our Provider Service Center at 1-866-235-2770.

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4. PAYMENT TO PROVIDERS

Plan Payment
WellCare PFFS reimburses deemed providers at the amount they would have received as participating or non-participating physicians, as applicable, under Original Medicare, minus any member required cost-sharing, for all medically necessary services covered by Medicare. We will process and pay clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, then we will pay interest on the claim according to Medicare guidelines. Section 5 has more information on prompt payment rules. Payment to providers for which Medicare does not have a publicly published rate will be based on the estimated Medicare amount. For more detailed information about our payment methodology for all provider types, go to www.wellcarepffs.com/provider/claiminformation.

Services covered under WellCare PFFS that are not covered under Original Medicare are reimbursed using WellCare PFFS vendors’ fee schedule. Please call us at 1-866-235-2770 to receive information on our fee schedule.

Deemed providers furnishing such services must accept the fee schedule amount, minus applicable member cost-sharing, as payment in full.

Member Benefits and Cost-Sharing
Payment of cost-sharing amounts is the responsibility of the member. Providers should collect the applicable cost-sharing from the member at the time of the service when possible. You can only collect from the member the appropriate WellCare PFFS co-payments or coinsurance amounts described in these terms and conditions. After collecting cost-sharing from the member, the provider should bill WellCare PFFS for covered services. Section 5 provides instructions on how to submit claims to us. If a member is a dual-eligible Medicare beneficiary (that is, the member is enrolled in our PFFS plan and a state Medicaid program) that the state holds harmless for Medicare cost-sharing, then the provider cannot collect any cost-sharing from the member at the time of service. Instead, the provider may only look to the state Medicaid agency to collect the Medicaid allowable cost-sharing amount(s).

To view a complete list of covered services and member cost-sharing amounts under WellCare PFFS, go to www.wellcarepffs.com/ourplans/ourplans. You may call us at 1-866-235-2770 to obtain more information about covered benefits, plan payment rates and member cost-sharing amounts under WellCare PFFS. Be sure to have the member’s ID number when you call.

WellCare PFFS follows Medicare coverage decisions for Medicare-covered services. Services not covered by Medicare are not covered by WellCare PFFS, unless specified by the plan. Information on obtaining an advance coverage determination can be found in Section 7. WellCare PFFS does not require members or providers to obtain prior authorization, prior notification or referrals from the plan as a condition of coverage. Under prior authorization, a plan requires beneficiaries or providers to seek authorization from the plan prior to obtaining services. There is no such requirement for WellCare PFFS members.

Note: Medicare supplemental policies, commonly referred to as Medigap plans, cannot cover cost-sharing amounts for Medicare Advantage plans, including PFFS plans. All cost-sharing is the member’s responsibility.

Balance Billing of Members
A provider may collect only applicable plan cost-sharing amounts from WellCare PFFS members and may not otherwise charge or bill members. Balance billing is prohibited by providers who furnish plan-covered services to WellCare PFFS members.

Hold Harmless Requirements
In no event, including, but not limited to, nonpayment by WellCare PFFS, insolvency of WellCare PFFS, and/or breach of these terms and conditions, shall a deemed provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a member or persons acting on their behalf for plan-covered services provided under these terms and conditions. This provision shall not prohibit the collection of any applicable coinsurance, co-payments or deductibles billed in accordance with the terms of the member’s benefit plan.

If any payment amount is mistakenly or erroneously collected from a member, you must make a refund of that amount to the member.

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5. FILING A CLAIM FOR PAYMENT

• 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, which is within 15-27 months from the date of service. (For services received between October 1, 2007, and September 30, 2008, claims must be submitted by December 31, 2009. For services received between October 1, 2008, and September 30, 2009, claims must be submitted by December 31, 2010.) 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 60 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 is 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.
  • 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.
   
• Where to submit a claim:

For electronic claim submission,
Contact:
Emdeon Business Services between 8am and 8pm Eastern at 1-800-845-6592, or register online 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.)
 

For paper claim submission,
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

• If you have problems submitting claims to us or have any billing questions, contact our technical billing resource at 1-866-235-2770.

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6. MAINTAINING MEDICAL RECORDS AND ALLOWING AUDITS

Deemed providers shall maintain timely and accurate medical, financial and administrative records related to services they render 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 must provide WellCare, the Department of Health and Human Services, the Comptroller General, or their designees access to 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: Centers for Medicare & Medicaid Services 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 PFFS 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.

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7. GETTING AN ADVANCE COVERAGE DETERMINATION

Providers may choose to obtain a written advance coverage determination (also known as an organization determination) from us before furnishing a service in order to confirm whether the service is medically necessary and will be covered by WellCare PFFS. To obtain an advance coverage determination, call us at 1-866-235-2770 or fill out the form located at www.wellcarepffs.com/provider/forms and fax it to 1-813-464-8764. WellCare PFFS will make a decision and notify you within 14 days of receiving the request, with a possible 14-day extension either due to the member’s request or WellCare PFFS justification that the delay is in the member’s best interest. In cases where you believe that waiting for a decision under this 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, call us at 1-866-235-2770 or fill out the form located at www.wellcarepffs.com/provider/forms and fax it to 1-813-464-8764. We will notify you of our decision within 72 hours.

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, providers have the right to dispute our decision by exercising member appeals rights.

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8. 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.
P.O. Box 4438
Scranton , PA 18505
Fax: 1-866-473-9122

A copy of our Provider Payment Dispute Resolution Form is available at www.wellcarepffs.com/provider/forms. 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

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9. MEMBER AND PROVIDER APPEALS AND GRIEVANCES

WellCare PFFS members have the right to file appeals and grievances when they have concerns or problems related to coverage or care. Members may appeal a decision made by WellCare PFFS to deny coverage or payment for a service or benefit that they believe should be covered or paid for. Members should file a grievance for all other types of complaints.

A provider may appeal decisions on behalf of a member as an appointed representative, or appeal on his or her own right using the member’s appeal process by signing a waiver of liability (promising to hold the member harmless regardless of the outcome). There must be existing potential member liability (e.g., a claim, as opposed to an advance coverage determination, is denied as not a medically necessary or a covered service) in order for a provider to appeal utilizing the member’s appeal process. If you appeal on your own right, you agree to abide by the statutes, regulations, standards and guidelines applicable to the Medicare PFFS Member appeals and grievance process.

The WellCare PFFS Member Evidence of Coverage (EOC) provides more detailed information about the member appeal and grievance process. The member EOC is posted under the member benefits link on the member information section of our Web site located at www.wellcarepffs.com/ourplans/ourplans. You can call member Customer Service at 1-866-238-9898 (TTY/TDD: 1-866-239-6265) Monday-Friday, 8am to 8pm Eastern for more information on our member appeals and grievance policies and procedures.

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10. 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. In addition, the provider should send a copy of any NOMNC issued to P.O. Box 31490, Tampa, FL 33631-3490 or fax to 1-813-464-8764.

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.

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11. IF YOU NEED ADDITIONAL INFORMATION OR HAVE QUESTIONS

If you have general questions about WellCare PFFS terms and conditions of payment, contact us at:

WellCare PFFS Provider Relations
1-866-235-2770
(TTY/TDD: 1-866-239-6265)
Monday-Friday, 8am to 8pm Eastern
P.O. Box 31405
Tampa , FL 33631-3405

Provider payment dispute resolution fax:	1-866-473-9122
Provider appeal for medical necessity and/or benefits fax:	1-866-201-0657
Provider advance determination fax:	1-813-464-8764
Provider Pharmacy (Coverage Determination form) fax:	1-877-277-1809
www.wellcarepffs.com
If you have questions about submitting claims, call us at	1-866-235-2770
If you have questions about plan payments, call us at	1-866-235-2770

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M0012_NA09204_FFS_INS_ENG (11/28/2008)