wellcare of south carolina timely filing limit wellcare of south carolina timely filing limit

Visit https://msp.scdhhs.gov/appeals/ to: Copyright 2023 Wellcare Health Plans, Inc. https://msp.scdhhs.gov/appeals/site-page/file-appeal, If we deny or limit a service you or your doctor asks us to approve, If we reduce, suspend or stop services youve been getting that we already approved, If we do not pay for the health care services you get, If we fail to give services in the required timeframe, If we fail to give you a decision in the required timeframe on an appeal you already filed, If we dont agree to let you see a doctor who is not in our network and you live in a rural area or in an area with limited doctors, If you dont agree with a decision we made regarding your medicine, We denied your request to dispute a financial liability, The member did not personally receive the notice of action or received the notice late, The member was seriously ill, which prevented a timely appeal, There was a death or serious illness in the members immediate family, An accident caused important records to be destroyed, Documentation was difficult to locate within the time limits; and/or the member had incorrect or incomplete information concerning the appeals process, Change the appeal to the timeframe for a standard decision (30 calendar days), Follow up with a written letter within 2 calendar days, Tell you over the phone and in writing that you may file a grievance about the denial of the fast appeal request, Be in writing and specify the reason for the request, Include your name, address and phone number, Indicate the date of service or the type of service denied, Your authorized representative (if youve chosen one), A hearing officer from Medicaid and Long-Term Care (MLTC), You or your authorized representative with your written consent must file your appeal with us and ask to continue your benefits within 10 calendar days after we mail the Notice of Adverse benefit determination; or, Within 10 calendar days of the intended effective date of the plans proposed action, whichever is later, The appeal or hearing must address the reduction, suspension or stopping of a previously authorized service, The services were ordered by an authorized provider, The period covered by the original authorization cannot have ended. A. 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. Incorrect forms will not be considered and may lead to further delays in processing prior authorization requests. Will Absolute Total Care change its name to WellCare? How do I determine if a professional or an outpatient bill type institutional submission should be filed to WellCare or Absolute Total Care? 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. Farmington, MO 63640-3821. A. Members will receive a 90-day transition of care period if the member is receiving ongoing care and treatment. 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. Wellcare wants to ensure that claims are handled as efficiently as possible. 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. For example, if any patient gets services on the 1st of any month then there is a time limit to submit his/her claim to the insurance company for reimbursement. The current transaction means that WellCare of South Carolina Medicaid members are transitioning to Absolute Total Care and will become Absolute Total Care members, effective April 1, 2021. On June 19, 2018, the Family and Social Services Administration's ("FSSA") Indiana Health Coverage Programs ("IHCP") released provider bulletin BT201829 regarding revising the timely filing limit for Medicaid fee-for-service claims. It is 30 days to 1 year and more and depends on . Authorizations already processed by WellCare for any services on or after April 1, 2021, will be moved to Absolute Total Care and there is no need for the provider or member to request these services again. Q. Here are some guides we created to help you with claims filing. Q. Claims submission, correspondence, and contact resources will stay the same for the Medicare line of business. 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). 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. A. South Carolina DEPARTMENT OF HEALTH AND HUMAN SERVICES Post Office Box 8206 Columbia, South Carolina 29202-8206 www.scdhhs.gov November 24, 2009 ALL . Members will receive a 90-day transition of care period if the member is receiving ongoing care and treatment. Instructions on how to submit a corrected or voided claim. Federal Employee Program (FEP) Federal Employee Program P.O. Search for primary care providers, hospitals, pharmacies, and more! We would like to help your billing department get your EDI (claims and real time) transactions processed as efficiently as possible. If you need assistance with your appeal please call Absolute Total Care at 1-866-433-6041 (TTY: 711) and we will assist you in filing your appeal. Claims for services prior to April 1, 2021 should be filed to WellCare for processing. Providers interested in joining the Absolute Total Care vision network for routine vision services can contact Envolve Vision at 1-800-531-2818. Claim Filing AmeriHealth Caritas North Carolina, hereafter referred to as the Plan (where appropriate), is required by the North Carolina and federal regulations to capture specific data regarding services rendered to its members. Or it can be made if we take too long to make a care decision. 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. Wellcare uses cookies. Box 31224 Select Health Claims must be filed within 12 months from the date of service. If you request a hearing, the request must: A State Fair Hearing is a legal proceeding. Q. However, as of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. Please be sure to use the correct line of business prior authorization form for prior authorization requests. However, there will be no members accessing/assigned to the Medicaid portion of the agreement. Medicaid Claims Payment Policies Box 100605 Columbia, SC 29260. Claims for services on or after April 1, 2021 should be filed to Absolute Total Care for processing. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Refer to your particular provider type program chapter for clarification. It was a smart move. #~0 I This manual sets forth the policies and procedures that providers participating in the Absolute Total Carenetwork are required tofollow. For the latest COVID-19 news, visit the CDC. 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. Professional and Institutional Encounter EDI transactions should be submitted to WellCare of South Carolina Medicaid with Payer ID 59354. You do not appeal within 10 calendar days from when the Plan mails an adverse Notice of Action, or you do not request a hearing within 10 calendar days from when the Plan mails an adverse Notice of Appeals Resolution whichever is later. Please use the From Date Institutional Statement Date. 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. Please note - a representative may file for a member who: If the members request for appeal is submitted after 60 calendar days from the date on the NABD, then good cause must be shown in order for WellCare to accept the late request. 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. 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. ?-}++lz;.0U(_I]:3O'~3-~%-JM Or you can have someone file it for you. We are simplifying Medicare so you can choose and use an affordable local plan that will help you achieve your best possible health. WellCare offers participating providers EFT and ERA services at no charge through PaySpan Health. Register now at https://www.payspanhealth.com or contact PaySpan at providersupport@payspanhealth.com, or 877-331-7154. You, your friend, a relative, legal counsel or other spokesperson who has your written consent may ask for a State Fair Hearing. Explains rules and state, line of business and CMS-specific regulations regarding 837P EDI transactions. 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. Q. * Username. Providers are encouraged to visit the Provider Resources webpagefor manuals, forms, and resources related to claims submission, eligibility, prior authorization, and more. A. 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. Q. Q. Know the facts about Coronavirus (COVID-19) Our call centers, including the nurse advice line, are currently experiencing high volume. Absolute Total Care will honor all existing WellCare authorization approvals that include dates of service beyond March 31, 2021. Copyright 2023 Wellcare Health Plans, Inc. Claims will be processed according to timely filing provisions in the providers WellCare Participating Provider Agreement. Do I need to do anything additional to provide services on or after 4/1/2021 if I am in network with both WellCare and Absolute Total Care? 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. Reconsideration or Claim Disputes/Appeals: To have someone represent you, you must complete an Appointment of Representative (AOR) form. WellCare offers participating providers EFT and ERA services at no charge through PaySpan Health. To do so by phone, call Member Services at 1-888-588-9842 (TTY1-877-247-6272). Download the free version of Adobe Reader. With the completion of this transaction, we have created a premier healthcare enterprise focused on government-sponsored healthcare programs. We are proud to announce that WellCare is now part of the Centene Family. They are called: State law allows you to make a grievance if you have any problems with us. Absolute Total Care will honor those authorizations. You and the person you choose to represent you must sign the AOR statement. All dates of service prior to April 1, 2021 should be filed to WellCare of South Carolina. Please Explore the Site and Get To Know Us. You can ask for a State Fair Hearing after we make our appeal decision. 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. We want to ensure that claims are handled as efficiently as possible. 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. Continuation of Benefits During the Appeals Process We will continue covering your medical services during your appeal request and State Fair Hearing if all of the following are meet. For dates of service on or after 4/1/2021: 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. Welcome to WellCare Provider Login Contact Us Join Our Network Medicaid Medicare Tools News and Education AcariaHealth Specialty Pharmacy Pharmacy Forms Request for Drug Coverage Request to Review Drug Coverage Denial . Q. This gives members time to establish with a new provider in the network and ensure that they have continuity of care. Hearings are used when you were denied a service or only part of the service was approved. Box 8206 Columbia, SC 29202-8206 Or call 1-800-763-9087. P.O. The member will be encouraged to establish care with a new in network PCP/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 try to make filing claims with us as easy as possible. You can file the grievance yourself. If Statement Range is April 2, 2021 through April 10, 2021, please send to Absolute Total Care. 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. Our call centers, including the nurse advice line, are currently experiencing high volume. Q. Will my existing WellCare patients be assigned to my Absolute Total Care Panel? Awagandakami 837 Institutional Encounter 5010v Guide * Password. A. South Carolina | Wellcare SOUTH CAROLINA Healthcare done well. z4M0(th`1Lf`M18c BIcJ[%4l JU2 _ s Date of Occurrence/DOSApril 1, 2021 and after: Processed by Absolute Total Care. Explains rules and state, line of business and CMS-specific regulations regarding 837I EDI transactions. The Claim Reconsideration process is an informal claim review, and is not a substitute for an appeal of a final agency decision. Division of Appeals and Hearings You and the person you choose to represent you must sign the AOR form. If you ask for a fast appeal and we decide that one is not needed, we will: You or your authorized representative can give us more information if you think itll help your appeal (regular or fast). P.O. DOS April 1, 2021 and after: Processed by Absolute Total Care. BlueCross BlueShield of South Carolina Piedmont Service Center P.O. The rules include what we must do when we get a grievance. WellCare understands that having access to the right tools can help you and your staff streamline day-to-day administrative tasks. How do I bill a professional submission with services spanning before and after 04/01/2021? Send your written appeal to: We must have your written consent before someone can file an appeal for you. The participating provider agreement with WellCare will remain in-place after April 1, 2021. Explains rules and state, line of business and CMS-specific regulations regarding 837P EDI transactions. you have another option. 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. Thanka kaa yoa Tufrbeau ingsnh ngetfu South Caralaita nouMa mpvd. Providers can help facilitate timely claim payment by having an understanding of our processes and requirements. Copyright 2023 Wellcare Health Plans, Inc. 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 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. South Carolina Department of Health and Human Services Division of Appeals and Hearings P.O. Please use the earliest From Date. For example, if a payer has a 90-day timely filing requirement, that means you need to submit the claim within 90 days of the date of service. You may do this in writing or in person. Outpatient Prior Authorization Form (PDF) Inpatient Prior Authorization Form (PDF) Ambetter Timely Filing Limit of : 1) Initial Claims. 2) Reconsideration or Claim disputes/Appeals. Absolute Total Care WellCare has partnered with Change Healthcare as our preferred EDI Clearinghouse. WellCare Medicare members are not affected by this change. (This includes your PCP or another provider.) We are proud to announce that WellCare is now part of the Centene Family. A. Transition/Continuity of Care is an extended period of time members are given when they join or transfer to another plan in order to receive services from out-of-network providers and/or pharmacies, until that specified period ends. 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 Yes, Absolute Total Care and WellCare will continue to offer Medicare products under their current brands and product names, until further notice. Examples of good cause include, but are not limited to, the following: We will send you a letter within five business days of getting your appeal. We process check runs daily, with the exception of Sundays, National Holidays, and the last day of the month. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, sex, or disability. 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. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Claims will be processed according to timely filing provisions in the providers Absolute Total Care Participating Provider Agreement. To do this: Be sure to ask us to continue your benefits within the 10 calendar day time frame. Coronavirus Disease 2019 (COVID-19) causes respiratory illness in people and can spread from person to person. Contact Wellcare Prime Provider Service at 1-855-735-4398 if you have questions. Will WellCare continue to offer current products or Medicare only? Beginning, March 14 March 31, 2021, please send to WellCare, April 1 April 3, 2021, please send to Absolute Total Care, DOS prior to 4/1/2021- Processed by WellCare, DOS 4/1/2021 and after- Processed by Absolute Total Care, Date of Occurrence/DOS prior to 4/1/2021- Processed by WellCare, Date of Occurrence/DOS 4/1/2021 and after- Processed by Absolute Total Care. DOS prior toApril 1, 2021: Processed by WellCare. 1096 0 obj <>stream To continue care with their current provider after the 90-day Transition of Care, the provider must agree to work with Absolute Total Care on the member's care and accept Absolute Total Care's payment rates. We are committed to improving the quality of life of our millions of members, who often include some of our nations most vulnerable populations. 3) Coordination of Benefits. WellCare and Absolute Total Care Medicare plans will continue to operate under current brands, product names and provider contracts, until further notice. You can file a grievance by calling or writing to us. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Professional and Institutional Encounter EDI transactions should be submitted to WellCare of South Carolina Medicaid with Payer ID 59354. As of April 1, 2021, all WellCare of South Carolina Medicaid members will transfer to Absolute Total Care. Providers can begin requesting prior authorization for pharmacy services from Absolute Total Care for dates of service on or after April 1, 2021 from Absolute Total Care on April 1, 2021. This manual sets forth the policies and procedures that providers participating in the Wellcare Prime network are required to follow. It will tell you we received your grievance. Contact Wellcare Prime Provider Service at1-855-735-4398if youhave questions. However, as of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. To do so by phone, call Member Services at 1-888-588-9842 (TTY1-877-247-6272). You can file your appeal by calling or writing to us. WellCare of South Carolina will be known as Absolute Total Care as of April 1, 2021. Q. 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. UnitedHealthcare Dual Complete Special Needs Plan UnitedHealthcare Dual Complete Special Needs Plans (SNP) offer benefits for people with both Medicare and Medicaid. 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. Explains rules and state, line of business and CMS-specific regulations regarding 837I EDI transactions. You now have access to a secure, quick way to electronically settle claims. WellCare claims will be processed according to timely filing provisions in the providers WellCare Participating Provider Agreement. Absolute Total Care will utilize credentialing cycles from WellCare and Absolute Total Care so that providers will only need to recredential once every three years. With the completion of this transaction, we have created a premier healthcare enterprise focused on government-sponsored healthcare programs. A. 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 can begin requesting prior authorization from Absolute Total Care for dates of service on or after April 1, 2021 from Absolute Total Care on March 15, 2021. Call us to get this form. What is the Rx BIN and Group Number for WellCare members transitioning to Absolute Total Care on April 1, 2021? 1044 0 obj <> endobj 2023 Medicare and PDP Compare Plans and Enroll Now Notice of Non-Discrimination We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, sex, or disability. All dates of service on or after 4/1/2021 should be filed to Absolute Total Care. A. WellCare Medicaid members migrating to Absolute Total Care will be assigned to their assigned WellCare Primary Care Physician (PCP) as if the PCP is in network with Absolute Total Care. We expect this process to be seamless for our valued members and there will be no break in their coverage. For as long as your member has an active WellCare subscriber number, you should continue to submit claims directly to WellCare as you have in the past. Box 31384 DOS prior to April 1, 2021: Processed by WellCare. If you file a grievance or an appeal, we must be fair. Q. S< 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. With quality healthcare solutions, Ambetter from Absolute Total Care helps residents of South Carolina live better. WellCare Medicare members are not affected by this change. Beginning. L]4(f4/pn~YTZSp-5/O*F)e~p:a6o{x8r Molina Healthcare of Michigan, 100 W. Big Beaver Road, Suite 600 Attn: Claims, Troy, MI 48084-5209 Or Fax to: (248) 925-1768. At the hearing, well explain why we made our decision. We encourage you to check the Medicaid Pre-Auth Check Tool in the For Providers section on the Absolute Total Care website at absolutetotalcare.com to ensure that you are accessing the most current Absolute Total Care authorization requirements for dates of service on or after 4/1/2021. Resources 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. 941w*)bF iLK\c;nF mhk} Transition/continuity of care is an extended period of time members are given when they join or transfer to another plan in order to receive services from out-of-network providers and/or pharmacies, until that specified period ends. You may request a State Fair Hearing at this address: South Carolina Department of Health In South Carolina, WellCare and Absolute Total Care are joining to better serve you. We expect this process to be seamless for our valued members, and there will be no break in their coverage. 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.