Wellcare By Allwell

Special Supplemental Benefits for Chronically Ill (SSBCI) are offered to Wellcare’s highest-risk members who meet specific criteria for eligibility based on the Centers for Medicare and Medicaid Services (CMS) guidelines.

Effective January 1, 2023, you can check eligibility requirements and submit attestations on behalf of members online at ssbci.rrd.com

Steps to determine eligibility, submit attestations and activate benefits

Members are required to schedule an office visit with their doctor or participating physician group for evaluation. Once appointment is made follow the steps below:

1. Visit ssbci.rrd.com.
2. Follow the steps on ssbci.rrd.com to evaluate your patient against the eligibility requirements outlined on ssbci.rrd.com.
3. Submit an attestation form through ssbci.rrd.com indicating your patient meets the eligibility requirements.
4. Submit a claim with the appropriate diagnosis codes from this office visit indicating a member has been diagnosed with one or more qualifying chronic conditions listed on ssbci.rrd.com.
5. Upon receipt of all required information, the member will be sent an approval or denial letter within 10 business days. Approval letters include information on steps the member should follow to activate supplemental member benefits.

If you have questions regarding the information contained in this update, contact 866-999-3945.

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:

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.

Submit Attestations Online for Chronically Ill Members

Effective January 1, 2023, fax attestations are no longer accepted

Special Supplemental Benefits for Chronically Ill (SSBCI) are offered to Wellcare’s highest-risk members who meet specific criteria for eligibility based on the Centers for Medicare and Medicaid Services (CMS) guidelines.

Effective January 1, 2023, you can check eligibility requirements and submit attestations on behalf of members online at ssbci.rrd.com

Steps to determine eligibility, submit attestations and activate benefits

Members are required to schedule an office visit with their doctor or participating physician group for evaluation. Once appointment is made follow the steps below:

1      Visit ssbci.rrd.com.

2      Follow the steps on ssbci.rrd.com to evaluate your patient against the eligibility requirements outlined on ssbci.rrd.com.

3      Submit an attestation form through ssbci.rrd.com indicating your patient meets the eligibility requirements.

4      Submit a claim with the appropriate diagnosis codes from this office visit indicating a member has been diagnosed with one or more qualifying chronic conditions listed on ssbci.rrd.com.

5      Upon receipt of all required information, the member will be sent an approval or denial letter within 10 business days. Approval letters include information on steps the member should follow to activate supplemental member benefits.

If you have questions regarding the information contained in this update, contact 866-999-3945.