2008 WellCare Private Fee-for-Service (PFFS) Terms and Conditions of Payment

 

 
 

Introduction

Concert, Sonata, Prelude and Melody are Medicare Advantage Private Fee-for-Service (PFFS) plans offered by WellCare Health Plans, Inc. Though these plans may have contracted providers, any eligible physician, hospital or other health care provider may choose to provide services to a WellCare PFFS member if they agree to accept WellCare’s Terms and Conditions and are deemed. In return, they will receive reimbursement for covered health services based on current Original Medicare rates, reimbursement guidelines and methodologies, less the member’s cost-sharing amounts.

Some key points about the PFFS plans:

  • PFFS plans are not HMOs or PPOs.
     
  • Referrals or preauthorizations of health care services are not required.
     
  • Provider reimbursement is based on published Original Medicare rates, reimbursement guidelines and methodologies, less the member’s cost-sharing amounts. Medicare Local Medical Review Policies apply.
     
  • WellCare PFFS directly reimburse 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

    Physician, hospital or other health care providers may choose to provide services to a WellCare PFFS member if they:
    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, and have not been sanctioned, or have not opted out of Medicare;
     
  • 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);
     
  • Comply with all Medicare and other federal health care program laws, regulations and program instructions that apply to the 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” found under the “Claim and Reimbursement Information” option of the “Providers” link at www.wellcarepffs.com.

    If the physician or provider has any questions 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 may visit www.wellcarepffs.com and select “Eligibility & Benefits” to validate eligibility;
       
  • Agree to render services to a WellCare PFFS member;
     
  • Agree to bill WellCare PFFS for reimbursement for Medicare-covered services and
     
  • Will only collect from members their WellCare PFFS plan cost-sharing amounts and agree to not 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)” and the “Detailed Notice of Discharge (CMS 10066)” 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 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” in this document and
     
  • The service(s) provided is/are covered by the member’s WellCare PFFS plan.
     

    • In addition, if a member enters a hospital for nonemergency 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.

     

    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 Medical Review Policies will apply.

    Please review payment methodology outlined by service type in the “Proxy Payment Grid” located in the “Claim & Reimbursement” section under the “Providers” link at www.wellcarepffs.com or request a copy by calling our Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern.

    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.

    Providers who have submitted claims to WellCare PFFS may register to view claims status online at the “Claim & Reimbursement” section under the “Providers” link at www.wellcarepffs.com

    .

     

    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 their WellCare PFFS plan, the member or provider then has the right to contact the plan to ask for an advance coverage decision.

     

    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 Overview, please select the option “Our Plans” at www.wellcarepffs.com or contact our Provider Service Center at 1-866-235-2770 (TTY/TDD: 1-866-239-6265). 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.

    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.

    If you have any questions about whether a service is covered under a WellCare PFFS plan or 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. Providers should ensure they adhere to all industry standards and state and federal requirements. In addition to coverage/medical necessity determinations and appropriate billing practices, medical records may be requested by a WellCare PFFS plan for risk adjustment validation audits as required by CMS.

    When the regulations expressly require providers to submit medical records

    The MA regulation at 42 CFR § 422.310(e) requires providers to submit medical records to ensure CMS can validate an MA plan’s risk adjustment data. This process occurs annually and is limited to specific beneficiaries in a subset of MA plans. Generally, CMS will direct the MA organization sponsoring the plan chosen for a sample to secure medical records on its behalf.

    Providers may be required to provide medical records, if beneficiaries for which they have been paid by WellCare are selected for CMS audit.

    When the regulations do not expressly require providers to submit medical records, but such records are required for compliance with regulations

    In addition, PFFS plans will need to obtain medical records in instances where the beneficiary or the provider requests an advance determination of coverage from the PFFS plan. PFFS plans may also obtain additional medical records from providers in order to determine if (1) the service furnished by a provider to a beneficiary is covered by the plan; (2) the service was reasonable and medically necessary or (3) the plan was billed correctly for the service that was furnished to the beneficiary.

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

     

    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. 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.

    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.

    For more information on how to submit a clean claim to WellCare review the “Claims submission guidelines” document on the “Claim & Reimbursement” section under the “Providers” link at www.wellcarepffs.com or request the information by calling our 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:

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

     

    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 non-covered services solely at the expense of the member, as long as the physician or provider have clearly informed the member that their WellCare PFFS plan 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, contact the Provider Service Center by:

    • Calling 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  

    Only National Provider Identifiers (NPIs) are to be reported on all Medicare CMS-1500 and CMS-1450 (UB-04) claims in the required primary 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 Resolution and Appeals

    Physicians, hospitals and other providers who render services to WellCare PFFS members agree to abide by the WellCare appeal and grievance procedures. Physicians and/or other health care professionals have the right to appeal 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. WellCare reserves the right to retrospectively review claims for claims payment accuracy based on the information submitted.

    WellCare PFFS plans’ claim dispute and appeals procedures and appropriate forms can be found in the WellCare PFFS plans “Provider Resource Guide” or under “Providers” at www.wellcarepffs.com.

     

    Provider Claim Payment Resolution Process

    A provider has sixty (60) days 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 Form” located both in the forms section of the WellCare PFFS plans “Provider Resource Guide” and on “Provider Forms” under “Providers” at www.wellcarepffs.com . You can also contact the Provider Service Center for a copy of the form.
       
    • The “Provider Claim Payment Resolution 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- 888-877-8238

    • 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 Resolution submission or status. 

     

    Provider Appeal for Medical Necessity and/or Benefits Process

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

    • The provider should submit his or her request of appeal using the “Provider PFFS Appeal Request” form located both in the forms section of the WellCare PFFS plans “Provider Resource Guide” and on “Provider Forms” under “Providers” at www.wellcarepffs.com. You can also contact the Provider Service Center for a copy of the form.
       
    • The “Provider PFFS Appeal Request” 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 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.

     

    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, 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 for questions about coverage determinations, exception requests, appeals or grievances, by contact Customer Service at 1-866-238-9898 (TTY/TDD: 1-866-239-6265 ) Monday - Friday, 7am 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.  

     

    Disclaimer: 2008 WellCare Private Fee-for-Service (PFFS) Terms and Conditions of Payment replaces the 2007 Terms and Conditions of Participation.

    Last modified: 05/05/2008