All providers, including provider employees and subcontractors, their employees and delegated entities are required to comply with Wellcare's compliance program requirements.
Provider Responsibilities
All participating providers are responsible for adhering to the Participation Agreement and the Provider Manual. The Provider Manual supplements the Agreement and provides information on requirements such as:
- Marketing Medicare Advantage plans
- Maximum Out-of-Pocket
- Provider billing and address change
- Provider access and availability, including after hours coverage
- Credentialing and re-credentialing requirements
- Provider, member termination and closing of physician panel
- Assisting members with special health care needs
- Claims and encounter data submission
- Medical records requirements, including Advance Directive and Living Wills documentation
- Mandatory participation in Quality Improvement projects and medical record review activities such as HEDIS
- Adhering to Wellcare's compliance requirements, including provider training and safeguarding member confidentiality in compliance with HIPAA
Wellcare Compliance Requirements
Our compliance requirements are included but not limited to:
- Provider Training Requirements
- Limitations on Provider Marketing
- Code of Conduct and Business Ethics
- Cultural Competency and sensitivity
- Fraude, despilfarro y uso indebido
- Americans with Disabilities Act
- Medical Records Retention and Documentation
Claims Submission
- Electronic and paper claims submissions must be HIPAA compliant
- All claims should include necessary, complete and correct and compliant data:
- Current CPT and ICD-9 (or 10) codes with appropriate modifiers
- Tax ID
- NPI number(s)
- Provider and/or practice names that match those on the W-9 initially submitted to Wellcare
- Valid Taxonomy code
- An authorization number, if applicable
Electronic Claims Submission
Wellcare encourages providers to submit electronically via Electronic Data Interchange (EDI) or Direct Data Entry (DDE). Both are less costly than paper and, in most instances, allow for quicker claims processing.
All claims and encounter transactions are validated for transaction integrity/syntax based on Strategic National Implementation Process (SNIP) guidelines.
Quality Improvement Program
Our members' care is of utmost importance to us. Our providers are contractually required to participate in Quality Improvement projects and medical records review activities.
Wellcare's Quality Improvement activities include, but are not limited to:
- Monitoring clinical indicators and outcomes
- Monitoring appropriateness of care
- Quality studies
- Healthcare Effectiveness Data and Information Set (HEDIS) measures
- Medical records audits
HEDIS is a mandatory process that occurs annually. It is an opportunity for Wellcare and our providers to demonstrate the quality and consistency of care that is available to members.
