Claims Department Box 6000 Greenville, SC 29606. Will WellCare continue to offer current products or Medicare only? From time to time, WellCare Health Plans reviews its reimbursement policies to maintain close alignment with industry standards and coding updates released by health care industry sources like the Centers for Medicare and Medicaid Services (CMS), and nationally recognized health and medical societies. The Medicare portion of the agreement will continue to function in its entirety as applicable. endstream endobj 1045 0 obj <>/Metadata 50 0 R/OpenAction 1046 0 R/Outlines 160 0 R/Pages 1042 0 R/StructTreeRoot 166 0 R/Type/Catalog/ViewerPreferences<>>> endobj 1046 0 obj <> endobj 1047 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageC/ImageB/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 1048 0 obj <>stream Paper Claim Submission Submit paper claims to: WellCare Health Plans Electronic Claim Submission To initiate electronic claims, both in-network and out-of-network providers should contact their practice management software vendor or EDI software vendor. Explains how to receive, load and send 834 EDI files for member information. Providers interested in joining the Absolute Total Care provider network should submit a request to the Network Development and Contracting Department via email at atc_contracting@centene.com. Claims for services prior to April 1, 2021 should be filed to WellCare for processing. What is the Rx BIN and Group Number for WellCare members transitioning to Absolute Total Care on April 1, 2021? Providers do not need to do anything additional to provide services on or after 4/1/2021 if the provider is in network with both WellCare and Absolute Total Care. An appeal may be filed within 60 calendar days from the date on the Adverse Benefit Determination Notice. As of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. A. WellCare of South Carolina will be known as Absolute Total Care as of April 1, 2021. Providers will continue to work directly with WellCare to address any claims for dates of service prior to the membership transfer of April 1, 2021. If you request a hearing, the request must: A State Fair Hearing is a legal proceeding. Explains how to receive, load and send 834 EDI files for member information. Claims submission, correspondence, and contact resources will stay the same for the Medicare line of business. However, as of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. UnitedHealthcare Dual Complete Special Needs Plan UnitedHealthcare Dual Complete Special Needs Plans (SNP) offer benefits for people with both Medicare and Medicaid. You must file your appeal within 60 calendar days from the date on the NABD. Incorrect forms will not be considered and may lead to further delays in processing prior authorization requests. Farmington, MO 63640-3821. They are called: State law allows you to make a grievance if you have any problems with us. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, sex, or disability. If you dont agree with our appeal decision - and you've completed the appeal steps with our health plan - or, if our appeal decision was not made within the required timeframe (30-calendar days for standard appeals or 72 hours for fast appeals), you may request a State Fair Hearing. No, Absolute Total Care will continue to operate under the Absolute Total Care name. At the hearing, well explain why we made our decision. Please Explore the Site and Get To Know Us. If Statement Range is April 2, 2021 through April 10, 2021, please send to Absolute Total Care. We will give you information to help you get the most from your benefits and the services we provide. Learn more about how were supporting members and providers. However, there will be no members accessing/assigned to the Medicaid portion of the agreement. As a member you may request a 14 day extension of your grievance, you may do so by calling Member Services at 1-888-588-9842 (TTY 1-877-247-6272) or You may send your request for extension in writing to: WellCare Health Plans A. Wellcare uses cookies. R 1/70.3/Determining End Date of Timely Filing Period -- Receipt Date R 1/70.4/Determination of Untimely Filing and Resulting Actions R 1/70.5/Application to Special Claim Types R 1/70.6/Filing Claim Where General Time Limit Has Expired R 1/70.7/Exceptions Allowing Extension of Time Limit R 1/70.7.1/Administrative Error Providers can begin requesting prior authorization from Absolute Total Care for dates of service on or after 4/1/2021 from Absolute Total Care on, Providers can begin requesting prior authorization for pharmacy services from Absolute Total Care for dates of service on or after 4/1/2021 from Absolute Total Care on. Q. DOS prior toApril 1, 2021: Processed by WellCare. Q. All dates of service on or after 4/1/2021 should be filed to Absolute Total Care. All transitioning Medicaid members will receive a welcome packet and new ID card from Absolute Total Care in March 2021 and will use the Absolute Total Care ID card to get prescriptions and access health care services starting April 1, 2021. Providers are encouraged to visit the Provider Resources page at absolutetotalcare.com for manuals, forms and resources related to claims submission, eligibility, prior authorization and more. This manual sets forth the policies and procedures that providers participating in the Absolute Total Carenetwork are required tofollow. Pregnant members receiving care from an out of network Obstetrician can continue to see their current Obstetrician until after the baby is born. If Medicare is the primary payer, timely filing is determined from the processing date indicated on the primary carrier's explanation of benefit (EOB) If Medicare is the Secondary Payer (MSP), the initial claim must be submitted to the primary payer within Cigna's timely filing period. We will continue covering your medical services during your appeal request and State Fair Hearing if all of the following are meet. Search for primary care providers, hospitals, pharmacies, and more! To have someone represent you, you must complete an Appointment of Representative (AOR) form. Prior authorizations issued by WellCare for dates of service on or after 4/1/2021 will transfer with the members eligibility to Absolute Total Care. WellCare Medicare members are not affected by this change. A. WellCare credentialing cycles will be shared with Absolute Total Care in order to reduce duplicative credentialing in the future. From time to time, Wellcare Health Plans reviews its reimbursement policies to maintain close alignment with industry standards and coding updates released by health care industry sources like the Centers for Medicare and Medicaid Services (CMS), and nationally recognized health and medical societies. Written notice is not needed if your expedited appeal request is filed verbally. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Please make sure you ask your members for a copy of their Absolute Total Care and Healthy Connections Choices Medicaid ID cards before each visit. L]4(f4/pn~YTZSp-5/O*F)e~p:a6o{x8r Exceptions to the one-year time limit: a) Medicare Cost Sharing Claims . Claims for services on or after April 1, 2021 should be filed to Absolute Total Care for processing. All Paper Claim Submissions can be mailed to: WellCare Health Plans Q. S< Providers will follow Absolute Total Care Medicaid policies and procedures for all services, inclusive of medical, behavioral, and pharmaceutical benefits, provided to WellCare Medicaid members transitioning to Absolute Total Care for dates of service on or after April 1, 2021. Reminder: It is important that providers check eligibility prior to providing services as members can potentially change plans prior to April 1, 2021 if they are in the annual choice period. Q. How do I determine if a professional or an outpatient bill type institutional submission should be filed to WellCare or Absolute Total Care? Earliest From Dates prior to April 1, 2021 should be filed to WellCare of South Carolina. We cannot disenroll you from our plan or treat you differently. The provider needs to contact Absolute Total Care to arrange continuing care. Member Appeals (Medical, Behavioral Health, and Pharmacy): Copyright 2023 Wellcare Health Plans, Inc. As of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. Will my existing WellCare patients be assigned to my Absolute Total Care Panel? A provider can act for a member in hearings with the member's written permission in advance. 1,flQ*!WLOmsmz\D;I5BI,yA#z!vYQi5'fedREF40 b666q1(UtUJJ.i` (T/@E With quality healthcare solutions, Ambetter from Absolute Total Care helps residents of South Carolina live better. The member will be encouraged to establish care with a new in network primary care provider/specialist prior to the end of the transition/continuity of care period to review present treatment plan and coordinate the member's medical care. We encourage you to check the Medicaid Pre-Auth Check Toolto ensure that you are accessing the most current Absolute Total Care authorization requirements for dates of service on or after April 1, 2021. Initial Claims: 120 Days from the Date of Service. Or it can be made if we take too long to make a care decision. These materials are for informational purposes only. Absolute Total Care Your second-level review will be performed by person(s) not involved in the first review. Yes, Absolute Total Care and WellCare will continue to offer Medicare products under their current brands and product names, until further notice. You will receive an acknowledgement letter within 5 business days, and we will send you a resolution within 90 calendar days. Q. A grievance is when you tell us about a concern you have with our plan. Claims Submission, Correspondence and Contact Resources will stay the same for the Medicare line of business. Date of Occurrence/DOSprior toApril 1, 2021: Processed by WellCare. You will have a limited time to submit additional information for a fast appeal. If you are unable to view PDFs, please download Adobe Reader. Providers are encouraged to visit the Provider Resources page at absolutetotalcare.com for manuals, forms and resources related to claims submission, eligibility, prior authorization and more. Member Appeals (Medical, Behavioral Health, and Pharmacy): You will need Adobe Reader to open PDFs on this site. Living Well Quality of Care Medicaid Managed Care Medicaid and CHIP Quality Resource Library Improvement Initiatives Performance Measurement Releases & Announcements Enrollment Strategies Continuous Eligibility Express Lane Eligibility Lawfully Residing Immigrant Children & Pregnant Women Presumptive Eligibility Home & Community Based Services The timely filing limit is the time duration from service rendered to patients and submitting claims to the insurance companies. We expect this process to be seamless for our valued members, and there will be no break in their coverage. Copyright 2023 WellCare Health Plans, Inc. WellCare Non-Emergency Medical Transportation (NEMT) Update, Provider Self-Service Quick Reference Guide (PDF), Provider Masters Level Proposed Rates (PDF), Member Advisory Committee (MAC) Member Flyer (PDF), Member Advisory Committee (MAC) - LTSS Member Flyer (PDF), Managed Care PHP Member PCP Change Request Form (PDF), Provider Referral Form: LTSS Request for PCS Assessment (PDF). Here you will find the tools and resources you need to help manage your submission of claims and receipt of payments. For dates of service on or after April 1, 2021: Absolute Total Care These SNP plans provide benefits beyond Original Medicare, and may include transportation to medical appointments and vision exams. Explains rules and state, line of business and CMS-specific regulations regarding 837I EDI transactions. If you need claim filing assistance, please contact your provider advocate. You or your authorized representative can review the information we used to make our decision. It is called a "Notice of Adverse Benefit Determination" or "NABD." Will Absolute Total Care continue to offer Medicare and Marketplace products? The second level review will follow the same process and procedure outlined for the initial review. Copyright 2023 Wellcare Health Plans, Inc. Download the free version of Adobe Reader. You can file your appeal by calling or writing to us. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. As of April 1, 2021, WellCare will no longer be a separate plan option offered by South Carolina Healthy Connections Choices. This must be done within 120 days from the date of Notice of Appeal Resolution you received from us. Copyright 2023 Wellcare Health Plans, Inc. Clinical Laboratory Improvement Amendments (CLIA). Get an annual flu shot today. Example of how to properly split claim that span the cutover date of April 1, 2021: Q. Providers are encouraged to visit the Provider Resources webpageformanuals, forms, clinical policies, payment policies, provider news and resources related to claims submission, eligibility, prior authorization and more. Synagis (RSV) - Medical Benefit or Retail Pharmacy, 17P or Makena - Medical Benefit or Retail Pharmacy, Special Supplemental Benefits for Chronically Ill (SSBCI), Screening, Brief Intervention, and Referral to Treatment (SBIRT), Patient Centered Medical Home Model (PCMH), Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), National Committee for Quality Assurance (NCQA), Hurricane Florence: What You Need to Know, Absolute Total Care Payment Policy and Edit Updates Effective 5/1/21, Notice About a New Payment Integrity Audit Program, Absolute Total Care Updated Guidance for Medicaid BabyNet Therapy Providers, Wellcare By Allwell Changing Peer-to-Peer Review Request and Elective Inpatient Prior Authorization Requirements for Medicare Advantage Plans, NEW Attestation Process for Special Supplemental Benefits for Chronically Ill (SSBCI), Medicare Prior Authorization Change Summary - Effective 1/1/2023. For general questions about claims submissions, call Provider Claims Services at 1-800-575-0418. Absolute Total Care will continue to offer Marketplace products under the Ambetter brand. If you file a grievance or an appeal, we must be fair. As of April 1, 2021, all WellCare of South Carolina Medicaid members will transfer to Absolute Total Care. South Carolina | Wellcare SOUTH CAROLINA Healthcare done well. This gives members time to establish with a new provider in the network and ensure that they have continuity of care. Members who are dealing with stress or anxiety can call our 24-Hour Behavioral Health Crisis Line at 1-833-207-4240 to speak with a trained professional. Please use the From Date Institutional Statement Date. From time to time, WellCare Health Plans reviews its reimbursement policies to maintain close alignment with industry standards and coding updates released by health care industry sources like the Centers for Medicare and Medicaid Services (CMS), and nationally recognized health and medical societies. We would like to help your billing department get your EDI (claims and real time) transactions processed as efficiently as possible. To earn rewards, members must: Download the Go365 for Humana Healthy Horizons app onto a mobile device from the Apple App Store or Google Play. Claims will be processed according to timely filing provisions in the providers Absolute Total Care Participating Provider Agreement. All transitioning Medicaid members will receive a welcome packet and new ID card from Absolute Total Care in March 2021 and will use the Absolute Total Care ID card to get prescriptions and access health care services starting April 1, 2021. As of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. WellCare of North Carolina Medicaid providers are not required to obtain an authorization for professional services for the 90-day post-go live period from July 1, 2021 through September 28, 2021. Providers are encouraged to sign up to receive EFT payments to avoid any payment delays. For requests involving dates of service on April 1, 2021 and beyond, Absolute Total Care will follow Medicaid contract requirements allowing a 90-day transition of care period. Contact Us Y0020_WCM_100876E Last Updated On: 10/1/2022 Synagis (RSV) - Medical Benefit or Retail Pharmacy, 17P or Makena - Medical Benefit or Retail Pharmacy, Special Supplemental Benefits for Chronically Ill (SSBCI), Screening, Brief Intervention, and Referral to Treatment (SBIRT), Patient Centered Medical Home Model (PCMH), Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), National Committee for Quality Assurance (NCQA), Hurricane Florence: What You Need to Know, Absolute Total Care Payment Policy and Edit Updates Effective 5/1/21, Notice About a New Payment Integrity Audit Program, Absolute Total Care Updated Guidance for Medicaid BabyNet Therapy Providers, Wellcare By Allwell Changing Peer-to-Peer Review Request and Elective Inpatient Prior Authorization Requirements for Medicare Advantage Plans, NEW Attestation Process for Special Supplemental Benefits for Chronically Ill (SSBCI), Medicare Prior Authorization Change Summary - Effective 1/1/2023. WellCare offers participating providers EFT and ERA services at no charge through PaySpan Health. Because those authorizations will automatically transfer to Absolute Total Care, it is not necessary to request the authorization again when the member becomes eligible with Absolute Total Care. Absolute Total Care will utilize credentialing cycles from WellCare and Absolute Total Care so that providers will only need to credential once every three years. Wellcare uses cookies. 1071 0 obj <>/Filter/FlateDecode/ID[<87133B316ADA4BDD8B85BA48A489D34F>]/Index[1044 53]/Info 1043 0 R/Length 117/Prev 692690/Root 1045 0 R/Size 1097/Type/XRef/W[1 2 1]>>stream You can get many of your Coronavirus-related questions answered here. Stay informed - activate your online account Behavioral Health Crisis Line 844-594-5076 (TTY 711) 24 hours a day, seven days a week Call us if you are experiencing emotional or mental pain or distress. Examples: If Statement Range is March 14, 2021 through April 3, 2021, please send to WellCare. WellCare of South Carolina will be known as Absolute Total Care as of April 1, 2021. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. You will get a letter from us when any of these actions occur. Need an account? Providers can begin requesting prior authorization for pharmacy services from Absolute Total Care for dates of service on or after 4/1/2021 from Absolute Total Care on April 1, 2021. We are glad you joined our family! Members will receive a 90-day transition of care period if the member is receiving ongoing care and treatment. Synagis (RSV) - Medical Benefit or Retail Pharmacy, 17P or Makena - Medical Benefit or Retail Pharmacy, Special Supplemental Benefits for Chronically Ill (SSBCI), Screening, Brief Intervention, and Referral to Treatment (SBIRT), Patient Centered Medical Home Model (PCMH), Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), National Committee for Quality Assurance (NCQA), Hurricane Florence: What You Need to Know, Absolute Total Care Payment Policy and Edit Updates Effective 5/1/21, Notice About a New Payment Integrity Audit Program, Absolute Total Care Updated Guidance for Medicaid BabyNet Therapy Providers, Wellcare By Allwell Changing Peer-to-Peer Review Request and Elective Inpatient Prior Authorization Requirements for Medicare Advantage Plans, NEW Attestation Process for Special Supplemental Benefits for Chronically Ill (SSBCI), Medicare Prior Authorization Change Summary - Effective 1/1/2023, Shortened Notification of Pregnancy (NOP) Provider Form (PDF), Notification of Pregnancy (NOP) Provider Form (PDF), Pregnancy Incentive Reimbursement Form (PDF), SCDHHS Form 1716 - Request for Medicaid ID Number - Infant (PDF), Member Appointment of Authorized Representative Form (PDF), SCDHHS Hospice Election/Enrollment Forms (PDF), Inpatient Prior Authorization Fax Form (PDF), Outpatient Prior Authorization Fax Form (PDF), SCDHHS Certificate of Medical Necessity (CMN) for Oxygen (PDF), Sick and Well Visit Reimbursement Letter (PDF), Claim Adjustments, Reconsiderations, and Disputes Provider Education (PDF), Obstetrical (OB) Incentive Programs (PDF), Provider Portal Enhancements: Claim Reconsideration and Denial Explanations (PDF), Outpatient Prior Authorization Form (PDF), Medicare Prescription Drug Coverage Determination Form (PDF), Authorization to Use and/or Disclose Health Information (PDF), Revocation of Authorization to Use and/or Disclose Health Information (PDF), Behavioral Health Psychological or Neuropsychological Testing Authorization Request Form (PDF), Electroconvulsive Therapy (ECT) Authorization Request Form (PDF), Behavioral Health Outpatient Treatment Request Form (PDF), Transitional Care Management Services Fact Sheet (PDF), Expedited Prior Authorization Request FAQ (PDF), Balance Billing Quick Reference Guide (PDF), 2021 Prior Authorization List Part B Appendix A (PDF), Bi-Annual Prior Authorization Update (PDF), 2021 Bi-Annual Prior Authorization Update Effective 8/1/21 (PDF), 2021 List of Covered Drugs (Formulary) Changes (PDF), New Century Health Implementation Notification (PDF), 2022 Wellcare by Allwell Provider Manual (PDF), Provider Reconsideration/Dispute Form (PDF), Behavioral Health Neuropsychological Testing Authorization Request Form (PDF), Behavioral Health Outpatient Treatement Request Form (PDF), Behavioral Health Electroconvulsive Therapy (ECT) Authorization Request Form (PDF), Electronic Funds Transfer (ETF) Features (PDF), 2021 List of Covered Drugs (Formulary) DSNP Changes (PDF), 2021 List of Covered Drugs (Formulary) HMO Changes (PDF). Provider can't require members to appoint them as a condition of getting services. All dates of service on or after April 1, 2021 should be filed to Absolute Total Care. Professional and Institutional Fee-For-Service/Encounter EDI transactions should be submitted to Absolute Total Care Medicaid with Payer ID 68069 for Emdeon/WebMD/Payerpath or 4272 for Relay Health/McKesson. Please use the From Date Institutional Statement Date. To ask for hearing, call 1-800-763-9087 or write to: You also can make a request online using SCDHHS form at https://msp.scdhhs.gov/appeals/site-page/file-appeal. WellCare is the health care plan that puts you in control. With the completion of this transaction, we have created a premier healthcare enterprise focused on government-sponsored healthcare programs. P.O. To write us, send mail to: You can fax it too. The rules include what we must do when we get a grievance. Please contact our Provider Services Call Center at 1-888-898-7969. hYnH~}9'I`@>cLq,&DYH"W~&eJx'"luWU]JDBFRJ!*SN(s'6# ^*dg4$SB7K4z:r6')baka+Raf4J=)l, _/jaSpao69&&_Ln=?/{:,'z .1J0|~jv4[eUN{:-gl! K'&hng?y},&X/|OzcJ@0PhDiO})9RA9tG%=|rBhHBz7 Obstetrician care provided by an out of network Obstetrician will be covered for pregnant members inclusive of post-partum care.
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