PROVIDERNewsletter

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SOUTH CAROLINA | 2014 | ISSUE III

PROVIDERNewsletter

MEMBERS’ RIGHTS AND RESPONSIBILITIES As a WellCare provider, it’s important for you to know what our members’ rights and responsibilities are.

OUR MEMBERS HAVE THE RIGHT TO: Receive information about our organization, services, practitioners and providers, and member rights and responsibilities

Be treated with respect and dignity

Have their privacy protected

Participate with practitioners in making decisions about their health care

Have a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost and benefit coverage

Voice complaints or appeals about WellCare or the care we provide*

Make recommendations regarding WellCare’s member rights and responsibilities policy

*Under WellCare’s Greivance Process and Administrative Review Process,members may file a grievance/complaint and may appeal medical or administrative decisions.

IN ADDITION, OUR MEMBERS HAVE THE RESPONSIBILITY TO: Supply information that WellCare, our practitioners and providers need to provide care

Follow plans and instructions for care that they have agreed on with their practitioner

Understand their health problems

Help set treatment goals that they agree to with their practitioner

Members may have additional rights and responsibilities. A complete listing can be found in the Provider Manual and the Member Handbook.

IN THIS ISSUE

Members’ Rights and Responsibilities .......Page 1

Admission Date Requirements

for Specific Claims .............................................Page 2

Depression Prevention Program ..................Page 3

Utilization Management Reviews

Ensure the Right Care .......................................Page 3

Q3 2014 Provider Formulary Update .........Page 3

WellCare Expands Collaboration

with CareCore National ..................................Page 4

South Carolina Benefit Changes:

(Effective July 1, 2014) ........................................Page 5

Submission Issues on the

New CMS 1500 Form ....................................... Page 6

Provider Claims Support Initiative .............Page 7

Provider Resources ........................................... Page 8

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ADMISSION DATE REQUIREMENTS FOR SPECIFIC CLAIMSWHEN IS AN ADMISSION DATE REQUIRED ON AN OUTPATIENT EDI 837I OR PAPER UB-04 CLAIM?Under specific requirements from the Centers for Medicare & Medicaid Services (CMS) and the National Uniform Billing Committee (NUBC) Guide, Outpatient claims sent by Electronic Data Interchange (EDI) 837I or paper UB-04 are required to contain the Start of Care date in the 2300 loop for EDI, or the Admission box for paper, for Home Health claim submission.

NUBC GUIDANCEThe NUBC Version 7.00 July 2012 Uniform Billing (UB) UB-04 2013 outlines Exceptions to the Inpatient/Outpatient requirements (page 18), and the NUBC Version 8.00 July 2013 Uniform Billing (UB) UB-04 2014 outlines Exceptions to the Inpatient/Outpatient requirements (page 19), to clarify when an admission date and/or time are required for UB-04 claim submissions. For Home Health claims, the admission date field is required to report the Start of Care date.

EXCEPTION LIST:

EXC.# DATA ELEMENTUSAGE REQUIREMENT BY TYPE OF BILL

EDI SUBMISSION LOCATIONPAPER SUBMISSION LOCATION

1Admission/Start of Care Date

Required on all inpatient claims AND Bill Types 012x, 022x, 032x, 033x, 034x, 081x and 082x

Loop 2300 DTP*435*D8* use D8 for date only (CCYYMMDD)

Box 12

2 Admission HourRequired for all inpatient claims except Bill Type 021x

Loop 2300 DTP*435*DT* use DT for date and hour (CCYYMMDDHHMM)

Box 13

The Usage Required by Type of Bill lists bill types 032x, 033x and 034x for Home Health claims (page 16 of the NUBC) as Outpatient, but subject to the Admission/Start of Care date requirement effective October 1, 2013. This means all of these bill types require the Admission/Start of Care date. Submission of the Admission hour on these bill types is not permitted.

CMS GUIDANCE FOR BILL TYPE 033XFor Home Health claims submitted on or after October 1, 2013, Medicare and Medicaid, no longer accepts institutional claims by EDI 837I or paper UB-04 submitted with bill type 033x. Since WellCare is required to comply with CMS guidelines, we also no longer accept this bill type for claims submitted on or after October 1, 2013.

Source: www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2694CP.pdf

STRATEGIC NATIONAL IMPLEMENTATION PROCESS (SNIP) REJECTIONS Home Health claims under bill types 032x or 034x that are submitted to WellCare and omit the Admission/Start of Care date will be SNIP rejected. These rejections can be caused by submission errors.

Examples:

1. The Admission/Start of Care date is missing;

2. The Admission/Start of Care date is present and the hour data is supplied in error; or

3. The Admission/Start of Care date is missing and the hour data is supplied in error.

Home Health claims under bill type 033x that are submitted to WellCare will be SNIP rejected for an invalid Bill Type.

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DEPRESSION PREVENTION PROGRAMDepression affects more than 6.5 million of the 35 million Americans aged 65 or older. Depression in older persons is closely associated with dependency and disability, and causes great distress for the individual and their family. Depression is also closely associated with chronic illnesses such as diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD) and stroke. To better foster collaboration, continuity and coordination between medical and behavioral health providers, WellCare has established a Depression Prevention Program. We encourage primary care providers to screen for depression and discuss with members the importance of appropriate follow-up with the right practitioner when issues and/or problems are identified. Proactive prevention, outreach and education programs are critical in helping members receive the appropriate behavioral health services regardless of age, ethnicity, gender or family background. We have created a variety of resources and tools to help providers screen for depression in members with chronic health conditions. These can be found on our website at www.wellcare.com/provider/depression_prevention_program.

UTILIZATION MANAGEMENT REVIEWS ENSURE THE RIGHT CAREWellCare’s Utilization Management (UM) program decision-making is based only on appropriateness of care, service and existence of coverage. We do not specifically reward UM decision makers or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

If you have questions about this program, please refer to your Quick Reference Guide at southcarolina.wellcare.com/WCAssets/southcarolina/assets/sc_caid_qrg_01_2014.pdf for contact information.

Q3 2014 PROVIDER FORMULARY UPDATE MEDICAID:Updates have been made to the WellCare of South Carolina Preferred Drug List (PDL). Please visit southcarolina.wellcare.com/provider/pharmacy to view the current PDL and pharmacy updates.

You can also refer to the Provider Manual at southcarolina.wellcare.com/WCAssets/southcarolina/assets/sc_medicaid_provider_manual_01_2013.pdf to view more information regarding WellCare of South Carolina’s pharmacy Utilization Management policies/procedures.

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WELLCARE EXPANDS COLLABORATION WITH CARECORE NATIONALWellCare currently collaborates with CareCore National to provide prior authorization for radiology, cardiology, sleep management and pain management requests. With your support, this collaboration ensures our commitment that members receive medically necessary covered services at the appropriate time and in the appropriate setting.

Pending final state approval, we are expanding our relationship with CareCore effective August 18, 2014, to include prior authorization requirements and post-service reviews for the following Medicaid outpatient procedures:

MOLECULAR AND GENETIC LABORATORY TESTING OUTPATIENT THERAPY SERVICES

Authorization for payment will be required for select Molecular Pathology Tier 1 and Tier 2 codes and Multianalyte Assays.

Examples include testing for:

BRCA

Long QT Syndrome

Lynch Syndrome

Oncotype DX®

PTEN Associated Conditions

Occupational and physical therapy visits for all outpatient rehabilitation and habilitation services.

Authorization will be required for accurate payment of claims for a limited range of CPT and HCPCS codes used for these services.

Authorizations of coverage will be for multiple dates of service as indicated and subject to benefit limits.

Note: Prior authorization is not required for these services when performed in an emergency room/department, urgent care facility, or during an inpatient stay.

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THE CLINICAL REVIEW PROCESSProviders should request authorization directly from CareCore prior to rendering these services, either online at www.carecorenational.com or by phone at 1-888-333-8641, Monday–Friday, 7 a.m. to 7 p.m.

Your time is valuable! So please take advantage of CareCore’s online authorization service. It’s quick and easy. Most cases can be completed online within four minutes, while the average phone authorization could take up to 15 minutes. Plus, the online service is available 24 hours a day, seven days a week for your convenience.

To minimize the need for further review by a CareCore clinical nurse or medical director, please have the patient’s chart available when calling so you can easily provide the following:

Insurance information

Member information (name, ID number, DOB)

Ordering or requesting provider information (name, address, TIN/UPIN/NPI)

Servicing provider information (name, address where test is to be performed)

CPT and ICD-9 Code (ICD-10 Code beginning Oct. 1, 2015)

Patient history including signs and symptoms

Results of previous studies and treatments as applicable

Treatment plan

Lab medical necessity review requires:

Relevant patient and family history including onset dates

An explanation of how test results will be used in this patient’s care

Additional information regarding the program will be posted on our provider website and updated regularly.

Any program changes that impact our Provider Manual will be communicated via Web bulletins and our provider newsletters.

If you have any questions, please contact WellCare Network Relations at 1-888-588-9769, Monday–Friday, 8 a.m. to 8 p.m.

SOUTH CAROLINA MEDICAID BENEFIT CHANGES: EFFECTIVE JULY 1, 2014Beginning July 1, 2014, WellCare of South Carolina will offer a $10 monthly Over-the-Counter (OTC) allowance for members. How it works:

Members will receive an OTC Catalog in the mail and choose the items they want.

Once they’ve selected their items, members will call the Customer Service number on their member ID cards and place their order.

The item(s) will arrive at the member’s doorstep in 7–10 days from the date the member placed an order.

Additionally, as of July 1, 2014, we will no longer offer the Boys & Girls Clubs benefit to members.

Members will be notified of these benefit changes via mail before July 1, 2014.

For questions about any of this information, talk with your PR rep or call the Provider Services team at 1-888-588-9842.

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SUBMISSION ISSUES ON THE NEW CMS 1500 FORM:WellCare has identified issues with paper submissions on the new paper CMS 1500 (02-12) form. Please use the following information to correct any claim rejection issues related to the new CMS 1500 form.

ICD INDICATOR:The new 1500 form requires identifying the ICD version being submitted in the ICD Ind. (Box 21) on the claim. The only acceptable values in this field are “9” for ICD9 or “0” for ICD10.

Note: WellCare is following the Center for Medicaid & Medicare Services (“CMS”) mandates and will continue to only accept ICD9 until mandated otherwise by CMS.

DIAGNOSIS FIELDS:CMS 1500 (08/05) and CMS 1500 (02-12) each have a Box 21 for entering the diagnosis codes but the code fields are configured differently on each form.

Column one: Column two:

1.______ 3. _____

2._____ 4. _____

On the CMS 1500 (08/05), 4 diagnosis code fields 1–4 were configured vertically in two columns in Box 21 as follows:

Line one:

A._____ B. _____ C.______ D.______

Line two:

E.______ F. _____ G._____ H._____

Line three:

I.______ J. _____ K._____ L.______

On the CMS 1500 (02-12), the 12 diagnosis code fields begin on the left-hand side of Box 21 and read, horizontally, left to right:

DIAGNOSIS POINTERS:The diagnosis pointers on each claim line must match the new Box 21 diagnosis labels. The allowable values for pointers are A–L.

BOX 17:If Box 17 is required for the Referring, Ordering, or Supervising provider’s name (First Name ‘space’ Last Name), the two-digit qualifier must be entered in the field to the left of the name.

(Example: DQ | John Smith)

BOX 17 QUALIFIERS:DN Referring Provider DK Ordering Provider DQ Supervising Provider

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PROVIDER CLAIMS SUPPORT INITIATIVEWellCare’s provider network plays an important role in ensuring members receive quality health care in a timely and cost-effective manner. Our Provider Services team is focused on how we deliver service to our provider network to ensure a positive experience. Our goal is to achieve the highest level of service and equip our provider call center agents with the right tools, resources and training to efficiently and effectively handle your call. To that end, we launched our Provider Claims Support (PCS) Initiative to all Medicaid/Medicare states the week of May 5, 2014.

THIS COMPREHENSIVE INITIATIVE INCLUDES: Tiered Provider Service team:

Tier 1 - Basic provider inquiry calls (eligibility, demo changes, callback request, education)

Tier 2 - All provider claims-related issues

Tier 3 - Claims adjustments (claims disputes and payment denials)

Call Routing: Enabled telephonic call prompts to allow providers to route directly to the PCS team

Training: Enhanced claims training to ensure agents are more proficient with claim inquiries by expanding their knowledge about claims rejections, real life claims scenarios and evaluating claims issues

Adjustments: Provided agents with the ability to perform real-time adjustments

Service Levels: Increased staffing to limit provider wait times to less than one minute and ensure most

issues are resolved during the first call

WHAT YOU CAN EXPECT: Dedicated team for claims status calls and all other transactions such as eligibility, authorization status and requirements

Dedicated team for handling most claim disputes with the ability to make adjustments in real time with no additional transfer or callbacks needed

Dedicated team to resolve more complex claims issues, claims rejections and payment policy disputes which may require more time for review and resolution. Providers should expect resolution or callback within 20 business days

Overall, improved service levels and turnaround times for the complex claims issues

This initiative, which serves to enhance the provider experience through improved resolution time frames, reduced wait times and better trained associates, presents a significant win.

In the end, this initiative creates a better relationship with our providers, and ultimately results in a better member experience.

Please continue to provide fact-based feedback to ensure we are continuously improving.

WellCare of South Carolina 1-888-588-9842 southcarolina.wellcare.com

WE’RE JUST A PHONE CALL OR CLICK AWAY!

WellCare of South Carolina 1-888-588-9842 southcarolina.wellcare.com

PROVIDER RESOURCES

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SC026278_PRO_NEW_ENG©WellCare 2014 SC_05_14 State Approved 07092014

PROVIDER RESOURCES

WEB RESOURCESVisit southcarolina.wellcare.com to access our Preventive and Clinical Practice Guidelines, Clinical Coverage Guidelines, Pharmacy Guidelines, key forms and other helpful resources. You may also request hard copies of any of the above documents by contacting your PR rep. For additional information, please refer your Quick Reference Guide at southcarolina.wellcare.com/WCAssets/southcarolina/assets/sc_caid_qrg_01_2014.pdf.

PROVIDER NEWSRemember to check messages regularly to receive new and updated information. Visit the secure area of southcarolina.wellcare.com to find copies of the latest correspondence. Access the secure portal using the “Member/Provider Secure Sign-In” area on the right. You will see Messages from WellCare located in the right-hand column.

ADDITIONAL CRITERIA AVAILABLEPlease remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for several medical procedures, devices and tests are available on our website at www.wellcare.com/provider/ccgs.

WE’RE JUST A PHONE CALL OR CLICK AWAY!