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Earlier this year, the Biden Administration announced that the federal Public Health Emergency (PHE) related to the COVID-19 pandemic will end on May 11, 2023.

During the PHE, we followed guidance from the Centers for Medicaid & Medicare Services (CMS) and instituted temporary waivers for select services. This action ensured that critical care could be quickly delivered to our members during a time of heightened need. Beginning May 12, 2023, these temporary waivers will expire, and our members’ Medicare plan benefits will be reinstated for the following services:

*Vaccine ingredient cost is still covered directly by Medicare FFS.

Alongside these waivers, the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency. This increase applied to claims that included the applicable COVID-19 ICD-10-CM diagnosis code and met the date of service requirement. When the PHE ends on May 11, 2023, these add-on payments will no longer be included for discharge dates of service as of May 12, 2023 and thereafter.

Wellcare is committed to providing a smooth transition for both our members and providers as we resume business as usual. While we will continue to communicate any updates to our business practices directly to our provider partners, we always highly recommend that providers verify member eligibility, benefits, and prior authorization requirements before rendering services.

Material ID: PRO_2081305E Internal Approved 05112023 

List effective 7/1/2023

Wellcare Oklahoma requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare Oklahoma.

Wellcare Oklahoma is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED. For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at https://www.oklahomacompletehealth.com/providers/preauth-check/medicare-pre-auth.html

• Prior Authorization Requirements and Part B Drug List (PDF)

List effective 1/1/2022

Wellcare requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare.

Wellcare is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.   

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at www.oklahomacompletehealth.com/providers/preauth-check/medicare-pre-auth

Effective January 1st, 2023, the following are changes to prior authorization requirements:

• Chart (PDF)
• Appendix A Part B (PDF)                                                          

In an effort to continue promotion of quality improvement for services provided to our members, Ambetter and WellCare of Oklahoma are pleased to announce a partnership with National Imaging Associates, Inc (NIA).

Ambetter, WellCare and NIA encourage our providers to attend an upcoming provider education webinar on the various programs administered by NIA. There are several one-hour webinar sessions that will take place on the following dates.

To register for one these informative webinars, please click the Provider Training link on the Oklahoma Complete Health website.* www.oklahomacompletehealth.com/providers/resources/provider-training.html

*It is recommended but not mandatory that you RSVP at least one week prior to the training that you plan to attend by registering for one of the education sessions above.

You will receive a registration confirmation email from NIA for the Webinar session you selected.  It is recommended that computer access is utilized if possible, to view educational documents during the webinar.  To access the webinar by computer, please click on the link for the session you would like to attend or type the URL address into your browser.  Please see call in instructions below if you do not have computer access.

NIA, Ambetter and Wellcare of Oklahoma look forward to working with you to ensure that your patients, our members receive services delivered in a quality, clinically appropriate fashion.

If you have questions about this bulletin or other provider resources, please contact the Oklahoma Complete Health Provider Support team at:

OklahomaCompleteHealth_PR@OCH.com

Or call Provider Services at:

•  Ambetter of Oklahoma (Marketplace): 1-833-492-0679 (TTY: 711)
•  Wellcare Oklahoma (Medicare Advantage): 1-833-853-0865 (TTY: 711)

Beginning on September 1, 2022, Wellcare of Oklahoma will be collaborating with Optum, to ensure consistency in claims review and reimbursement practices with our hospital partners by reviewing all facility claims that exceed outlier thresholds.     

Effective September 1, 2022, will require submission of itemized bills with high dollar facility claims.   You must submit an itemized detail listing each supply and service provided to the patient and match the billed charge amount for the underlying claim for submission of all facility outlier claims.  

Itemized Bill Requirements:

• The itemized bill must list each supply and services provided to the member, match the dollar amount and date of service of the request. 
• The request will apply to claims submitted with other insurance, changes in coverage, lapse in coverage, or if the member’s coverage termed during the length of stay. 
• Interim billing will not require an itemized bill, however it will be requested once the final bill has been submitted.

How will Company communicate its findings?

If Optum identifies any billing issues during its review, it will send you detailed findings regarding these issues and provide you with a direct contact with whom you can discuss and resolve any issues you may have with its findings.  You can also exercise your right to formally appeal Optum’s finding. 

Questions:

If you have questions about this communication, please contact Provider Relations at pr_wellcare_ok@oklahomacompletehealth.com.

Thank you for your continued partnership with Wellcare. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. 

Wellcare is issuing a new policy effective *4/1/2022*.

Policy Number: CC.PP.071

Policy Name: Evaluation and Management Services Billed with Treatment Rooms

Policy Description: Disallows E&M services in treatment rooms as this does not represent a treatment type of service.

Lines of Business: Medicare

For detailed information about this policy, please refer to our Clinical & Payment Policies [link: https://www.wellcareok.com/for-providers/clinical-payment-policies.html]. And for questions about this or any of our payment policies, please don’t hesitate to reach out to our Provider Services team at 1-833-853-0865.

Dear Valued Provider,

To reduce administrative burden on our provider partners, Wellcare is making the following changes to both our peer-to-peer review request requirements and elective medical inpatient authorization process. This will impact peer-to-peer and elective medical inpatient authorization requests received on or after the elective dates outlined below.

Peer-to-Peer Review Requests Change Effective 10/1/2022

In order to ensure accurate delivery and reimbursement for medically necessary services to our members, Wellcare is updating our requirements for peer-to-peer review effective 10/1/2022 to the following:

• Peer-to-peer review requests will be allowed up to two (2) business days after Integrated Denial Notice or day of discharge, whichever is later.
• Peer-to-peer outreach will be completed within 2 business days of peer-to-peer review request.
• If provider is not reached, a voice mail will be left (if possible) giving provider one business day to respond.
• If the provider does not respond within the stipulated timeframe, Wellcare will be unable to proceed with peer-to-peer request.

No changes are being made to existing peer-to-peer timeframes or processes for pre-service requests.

Elective Medical Inpatient Authorization Process Change Effective 11/1/2022

To provide increased flexibility and better align with industry best practices, we are making the following changes to our elective medial inpatient authorization process effective 11/1/2022:

• The prior authorization span for elective inpatient admissions will be increased to 60 (sixty) days for dates of service on or after 11/1/2022.
• If the planned admission date exceeds the authorized date span of 60 days, a new authorization span is required.
• Elective Inpatient Prior Authorization numbers will now start with the prefix of OP instead of IP.
• Notification of admission is required within one (1) business day of admit. At the time of admission notification, a new authorization number for the admission will be provided with the IP prefix. Failure to provide timely notification may result in a denial of payment.   

As a reminder, all planned/elective admissions to the inpatient setting require prior authorization. Prior authorization should be requested at least five (5) days before the scheduled service delivery date or as soon as need for service is identified. If prior authorization is not on file at the time of elective admission, the service is considered retrospective, and provider should follow the appropriate retrospective request process as communicated in the provider notice. Emergent admissions do not require prior authorization.

Thank you for continuing to provide our Medicare members with high quality and compassionate care. If you have questions about any of this information, please contact Provider Services.

Sincerely,

Wellcare

As a valued provider partner, we’d like to remind you to review your National Provider Identifier (NPI) data in National Plan & Provider Enumeration System (NPPES) as soon as possible to ensure that accurate provider data is displayed.  As you may know, providers are legally required to keep their NPPES data current. Centers for Medicare & Medicaid Services (CMS) is also encouraging Medicare Advantage Organizations to use NPPES as a resource for our online provider directories.  By using NPPES, we can decrease the frequency by which we contact you for updated directory information and provide more reliable information to Medicare beneficiaries. 

If the NPPES database is kept up to date by providers, our organization can rely on it as a primary data resource for our provider directories, instead of calling your office for this information.  With updated information, we can download the NPPES database and compare the provider data to the information in our existing provider directory to verify its accuracy.

When reviewing your provider data in NPPES, please update any inaccurate information in modifiable fields including provider name, mailing address, telephone and fax numbers, and specialty, to name a few.  You should also make sure to include all addresses where you practice and actively see patients and where a patient can call and make an appointment.  Do not include addresses where you could see a patient, but do not actively practice.  Please remove any practice locations that are no longer in use. Once you update your information, you will need to confirm it is accurate by certifying it in NPPES. Remember, NPPES has no bearing on billing Medicare Fee-For-Service. 

If you have any questions pertaining to NPPES, you may reference NPPES help at https://nppes.cms.hhs.gov/webhelp/nppeshelp/HOME%20PAGE-SIGN%20IN%20PAGE.html.
Please direct any general questions about this notice to your provider relations representative.