WellCare Post-Implementation Teleconference and s Introduction On the KMA hosted a teleconference with WellCare Kentucky Health Plan. The Medical Director for WellCare Kentucky, Cheryl Shafer, MD reminded offices not to cancel appointments or procedures since all physicians are considered participating until the end of the year. Dora Wilson, Chief Operating Officer also provided several updates. KMA members dialed in for the call to find out more about WellCare and ask questions related to the transition from traditional Medicaid to Medicaid Managed Care. Below is a summary of the questions and answers. Claims Submission/Clearinghouses Does WellCare interface with all electronic clearinghouses? WellCare uses RelayHealth, a division of McKesson to manage all Electronic Data Interchange (EDI) claims between WellCare and physicians and other providers. Many clearinghouses subcontract services which should allow for a smoother transition. If your office needs assistance in making a connection with RelayHealth, or if you have questions, contact RelayHealth at 1-888- 499-5465, or your vendor may call 1-888-743-8735 for more information. Can claims be resubmitted? Yes, offices may use the Direct Data Entry (DDE) to submit initial claims or correct claims. Medicaid MCO s and s
Dual Eligible Will cross- over claims (Cross-Over Claim - The transfer of claim data from Medicare to Medicaid or another insurer) be sent to Medicaid to complete to WellCare for dual eligible members (Medicare/Medicaid)? Yes. Electronic Funds Transfer/Electronic Remittance Advice If you currently receive payments and Remittance Advice electronically from the state will this continue with WellCare? Yes, you may receive payments and remittance advice electronically. First you must contact Payformance to request a registration code. Call 1-877-331-7154 or email providersupport@payspanhealth.com to request a registration form that must be completed and returned via fax to Payformance. Until you receive your registration code and complete your registration on-line, you will receive paper checks. Eligibility Verification How do I verify member eligibility with WellCare? Eligibility can be verified using the WellCare Provider Portal at www.kentuckywellcare.com. Medical Record Documentation Does the patient care plan go in the patient medical record chart? Yes. Medicaid MCO s and s
Payment Cycle How often will WellCare mail payment or deposit payments? Payments will be mailed or deposited on a daily basis. When will the first payments be mailed or deposited? The first payments were sent out on November 3, 2011. Primary Care Provider (PCP) Selection Some members have been assigned primary care physicians that do not provide primary care, for example Emergency Room physicians or Urgent Treatment Center physicians. How can an office correct this? Members must call WellCare Customer Service to change Primary Care Providers (PCPs). Prior-Authorization Is a prior-authorization required for MRIs, CAT SCANS, and PET SCANs? Yes, all such diagnostic tests require a prior-authorization. CareCore National is the WellCare innetwork radiology services vendor for all places of services (POS) except In-patient or Observation settings. The State allowed retroactive prior-authorizations. Will that process continue with WellCare? No. WellCare has a process in place to receive same-day authorizations by calling Prior- Authorization In-take. What is the fastest way to find out if a specific service requires a prior-authorization? Medicaid MCO s and s
For prior authorization requests, fax communication always works better with WellCare. However, if you have an urgent authorization request, call 877-389-9457 and ask for prior authorization intake for immediate assistance. Utilize the on-line quick reference guide to find out more about prior authorization requirements. Other reminders: Emergency behavioral services do not require authorization. Inpatient admission notification is required on the next business day following admission. All prior-authorization requests must be completed within 2 business days. If WellCare is the secondary payer, is a prior-authorization required on any service? No PA is required for outpatient services. WellCare does require notification for inpatient admissions. Referrals Is a paper referral needed for a member to see a OB-GYN Specialist? No referral is needed for any participating provider nor is a telephone call to WellCare required. Does an Oral Surgery practice need a referral from a dental practice? No referral is needed for participating providers nor is a telephone call to WellCare required.. Reimbursement Is after-hours coverage available? Medicaid MCO s and s
There are two codes 99050 and 99051 that should be used when billing for afterhours care and have a fee attached. What is the reimbursement for a Pap and Pelvic Exam when performed by the PCP? Only one pap and pelvic per year can be counted as preventive care. However, additional pap and pelvic exams may be done throughout the year and will be covered. These should not be coded as preventive. Specialists Is there a requirement for a pain management specialist to see the patient every month if prescribing a controlled substance? No. However, the Lock-in program will remain in place for some members that will lock them into one PCP, Pharmacy or hospital. I am calling from an Oral Surgery office. If I treat a dual eligible (Medicare and Medicaid) member for routine services that Medicare will not cover and I am going to bill the Medicaid plan, am I required to submit the claim to WellCare first? You are required to document that the service is not covered by Medicare, by billing Medicare first. Then WellCare will receive it on the crossover claim. If it is a service that requires prior authorization with WellCare then we will need to do that. If it does not, you can just submit the claim as above. At our OB/GYN office we see newborns at 2-weeks and they do not have a member card yet. Can we bill under the mother s member ID? Yes. You may bill under the mother s ID for the first 30-days. Medicaid MCO s and s