Wellcare By Allwell
Latest Updates and Notices for Wellcare By Allwell
New Centene Medicare CPT II and HCPCS $0.01 Billing program
Centene Medicare providers can now utilize the CPT II $0.01 Billing Program. The $0.01 Billing Program seeks to reimburse providers one penny on select HEDIS related CPT II and HCPCS codes that were previously non-reimbursed and often denied by claims clearinghouses. This program launched for Wellcare Plans in January 2019. This expansion means that now Centene Medicare providers can bill $0.01 on claims for 32 CPT II and 3 HCPCS codes that will close HEDIS care gaps, in addition to the many benefits this program has to offer.
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.
Adding prepay reviews for several national coverage determinations (NCDs) to be in accordance with CMS guidelines for correct coding.
NCDs: 150.3, 190.21, 20.4, 20.4Z, 210.10, 210.10Y, 210.1, 210.1Y, 210.1Z, 210.6, 210.7, 210.7Y, 220.13, 20.8.3
Wellcare By Allwell 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 By Allwell.
Wellcare By Allwell 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 our Online Prior Authorization Tool on our website.
Effective October 1, 2022, the following are changes to prior authorization requirements:
|Service Category||Change||Services||Procedure Codes|
|Wound Care||Remove PA||Excision of pressure ulcers||
15920, 15922, 15931, 15933, 15934, 15935, 15936, 15937, 15940, 15941, 15944, 15945, 15946, 15950, 15951, 15952, 15953, 15956, 15958
Burn debridement and dressing
16000, 16020, 16025, 16030, 16035, 16036
Ablative laser treatment, electromagnetic therapy
0491T, 0492T, G0329
Non-selective debridement, negative pressure wound treatment, low-frequency ultrasound
97602, 97605, 97606, 97607, 97608, 97610
Add PA after 12 visits per calendar year
11004, 11005, 11008, 11011, 11012, 11042, 11043, 11044, 11045, 11046, 11047
Wellcare By Allwell: Changing Peer-to-Peer Review Request and Elective Inpatient Prior Authorization Requirements for Medicare Advantage Plans
To reduce administrative burden on our provider partners, Wellcare By Allwell 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 November 1, 2022
To ensure accurate delivery and reimbursement for medically necessary services to our members, Wellcare is updating our requirements for peer-to-peer review effective November 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 November 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 November 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.
Wellcare By Allwell is proud to offer a comprehensive selection of Medicare plans in your area.
- Wellcare No Premium Medicare (HMO) – Contract #H0724-001
- Wellcare Patriot No Premium (HMO) – Contract #H0724-005
- Wellcare Assist Complement (HMO) – Contract #H0724-006
- Wellcare Giveback Boost (HMO) - Contract #H0724-007
- Wellcare No Premium (HMO) – Contract #0908-003
- Wellcare Assist (HMO) – Contract #H0908-004
- Wellcare Giveback (HMO) – Contract #H0908-005
- Wellcare No Premium Open (PPO) – Contract #H7169-001
- Wellcare Dual Access (HMO D-SNP) – Contract #H0908-001
New for 2022 is our Wellcare By Allwell Medicare Advantage PPO
With the Wellcare By Allwell Medicare Advantage PPO plan, members enjoy the freedom to receive healthcare services from Medicare providers of their choice. As an eligible Medicare provider, Wellcare By Allwell reimburses you at 100% of the Medicare allowable rate for all plan-covered, medically necessary services for our PPO members – whether you are contracted with us or not.
The Wellcare By Allwell Medicare Advantage PPO plan offers members flexibility as they navigate their care journeys. PPO members don’t need a referral from a primary care physician for specialist or hospital visits. However, using providers in Wellcare By Allwell’s network may cost less than choosing one that is out-of-network. Medicare providers who do not contract with Wellcare By Allwell are under no obligation to treat our members, except in emergency situations.
In addition, the Wellcare By Allwell Medicare Advantage PPO plan:
- Offers a simple copayment for doctor visits, hospital stays and many other healthcare services, making healthcare costs more predictable
- Gives members Medicare Parts A, B, and D coverage as well as vision, dental, and hearing benefits not covered by Original Medicare
- Covers all Original Medicare services and follows Original Medicare’s coverage rules
- Only covers medically necessary services rendered by providers who are eligible to participate in Medicare
If you provide services to a Wellcare By Allwell PPO member, whether you are in- or out-of-network, we make it easy to seek prior authorizations and submit claims. Please reference the table below for the web links and phone numbers to do so.
Referrals or authorizations to see out-of-network providers are not required, however they are highly encouraged.
- Wellcare By Allwell Payer ID: 68069
- Secure Provider Portal: Buckeye Health Plan/providers
- Prior Authorization Form: Prior Auth - Medicare
- Prior Authorization Fax (Medical): 833-660-1992
- Prior Authorization Fax (Behavioral Health):
Inpatient: 833-320-2895/Outpatient: 833-320-2892
- Transplant Requests Fax: 1-844-974-3115
- Expedited Prior Authorization Phone Number: 855-766-1851
- Provider Services: 855-766-1851
These phone numbers can be found in the top right corner of the form.
Note: Out-of-network providers should bill Wellcare By Allwell first. However, if the member has already paid, we will reimburse the member for our share of the cost for covered services.