If your services are continued during an appeal or a hearing, you can keep getting them until: If the hearing is decided in your favor, well approve and pay for the care that is needed. However, as of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. Wellcare uses cookies. Q. If you think you might have been exposed, contact a doctor immediately. A hearing officer from the State will decide if we made the right decision. 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. Ambetter from Absolute Total Care - South Carolina. Hearings are used when you were denied a service or only part of the service was approved. 2) Reconsideration or Claim disputes/Appeals. April 1-April 3, 2021, please send to Absolute Total Care. You can ask for a State Fair Hearing after we make our appeal decision. WellCare offers participating providers EFT and ERA services at no charge through PaySpan Health. Q. 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. Providers interested in joining the Absolute Total Care provider network should submit a request to the Network Development and Contracting Department via email at atc_contracting@centene.com. 1,flQ*!WLOmsmz\D;I5BI,yA#z!vYQi5'fedREF40
b666q1(UtUJJ.i` (T/@E WellCare Medicare members are not affected by this change. If you request a hearing, the request must: A State Fair Hearing is a legal proceeding. This manual sets forth the policies and procedures that providers participating in the Wellcare Prime network are required to follow. We will also send you a letter with our decision within 72 hours from receiving your appeal. Providers interested in joining the Absolute Total Care Provider Network should submit a request to Network Development and Contracting via email at. Q. R 1/70.3/Determining End Date of Timely Filing Period -- Receipt Date R 1/70.4/Determination of Untimely Filing and Resulting Actions R 1/70.5/Application to Special Claim Types R 1/70.6/Filing Claim Where General Time Limit Has Expired R 1/70.7/Exceptions Allowing Extension of Time Limit R 1/70.7.1/Administrative Error Professional and Institutional Encounter EDI transactions should be submitted to WellCare of South Carolina Medicaid with Payer ID 59354. 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. 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. WellCare of North Carolina partners with providers to develop and deliver high-quality, cost-effective health care solutions. This gives members time to establish with a new provider in the network and ensure that they have continuity of care. Our call centers, including the nurse advice line, are currently experiencing high volume. Our fax number is 1-866-201-0657. Where should I submit claims for WellCare Medicaid members? Members can continue to receive services from their current WellCare provider as long as they remain covered under WellCare. 2023 Medicare and PDP Compare Plans and Enroll Now. You and the person you choose to represent you must sign the AOR form. We may apply a 14 day extension to your grievance resolution. Molina Healthcare of Michigan, 100 W. Big Beaver Road, Suite 600 Attn: Claims, Troy, MI 48084-5209 Or Fax to: (248) 925-1768. 3) Coordination of Benefits. An appeal is a request you can make when you do not agree with a decision we made about your care. WellCare offers participating providers EFT and ERA services at no charge through PaySpan Health. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Timely filing is when you file a claim within a payer-determined time limit. With the completion of this transaction, we have created a premier healthcare enterprise focused on government-sponsored healthcare programs. Learn more about how were supporting members and providers. 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. All dates of service prior to 4/1/2021 should be filed to WellCare of South Carolina. You can get many of your Coronavirus-related questions answered here. These materials are for informational purposes only. Box 6000 Greenville, SC 29606. The participating provider agreement with WellCare will remain in-place after 4/1/2021. Providers will continue to follow WellCares Medicaid policies and procedures for services provided to WellCare Medicaid members for dates of service prior to April 1, 2021. A. 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. You will receive an acknowledgement letter within 5 business days, and we will send you a resolution within 90 calendar days. The second level review will follow the same process and procedure outlined for the initial review. To earn rewards, members must: Download the Go365 for Humana Healthy Horizons app onto a mobile device from the Apple App Store or Google Play. This person has all beneficiary rights and responsibilities during the appeal process. Explains rules and state, line of business and CMS-specific regulations regarding 837P EDI transactions. As of April 1, 2021, WellCare will no longer be a separate plan option offered by South Carolina Healthy Connections Choices. To do so by phone, call Member Services at 1-888-588-9842 (TTY1-877-247-6272). Refer to your particular provider type program chapter for clarification. Box 31384 P.O. All transitioning Medicaid members will receive a welcome packet and new member ID card from Absolute Total Care in March 2021 and will use the Absolute Total Care ID card to get prescriptions and access healthcare services starting April 1, 2021. 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. Box 3050 We would like to help your billing department get your EDI (claims and real time) transactions processed as efficiently as possible. P.O. Explains rules and state, line of business and CMS-specific regulations regarding 837I EDI transactions. Q. We will call you with our decision if we decide you need a fast appeal. \{-w{,xI202100$0*bZf ,X AayhP3pYla" e 3G& `eoT#@ *;d
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Within five business days of getting your grievance, we will mail you a letter. 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. This gives members time to establish with a new provider in the network and ensure that they have continuity of care. Shop or Enroll in a Plan Frequently Asked Questions Find a Doctor Download Digital ID Card Welcome Allwell Members! You will have a limited time to submit additional information for a fast appeal. Claims will be processed according to timely filing provisions in the providers WellCare Participating Provider Agreement. 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. Finding a doctor is quick and easy. Members can continue to receive services from their current WellCare provider as long as they remain covered under WellCare. Absolute Total Care will continue to offer Marketplace products under the Ambetter brand. For dates of service on or after April 1, 2021: Absolute Total Care We will do this as quickly as possible as but no longer than 72-hours from the decision. 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 . How will credentialing/recredentialing be handled by Absolute Total Care if a provider was recently credentialed/recredentialed by WellCare? The state has also helped to set the rules for making a grievance. 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. Earliest From Dates on or after 4/1/2021 should be filed to Absolute Total Care. In this section, we will explain how you can tell us about these concerns/grievances.
You will need Adobe Reader to open PDFs on this site. North Carolina PHP Billing Guidance for Local W Code. Providers can begin requesting prior authorization from Absolute Total Care for dates of service on or after 4/1/2021 from Absolute Total Care on, Providers can begin requesting prior authorization for pharmacy services from Absolute Total Care for dates of service on or after 4/1/2021 from Absolute Total Care on. When can providers begin requesting prior authorization from Absolute Total Care for WellCare Medicaid members for dates of service on or after April 1, 2021? A grievance is when you tell us about a concern you have with our plan. 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. $8v + Yu @bAD`K@8m.`:DPeV @l Tampa, FL 33631-3372. Register now. Providers can help facilitate timely claim payment by having an understanding of our processes and requirements. Reminder: It is important that providers check eligibility prior to providing services as members can potentially change plans prior to April 1, 2021 if they are in the annual choice period. Medicaid Claims Payment Policies What will happen to my Participating Provider Agreement with WellCare after 4/1/2021? Those who attend the hearing include: You can also request to have your hearing over the phone. 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. If Statement Range is April 2, 2021 through April 10, 2021, please send to Absolute Total Care. P.O. Claims will be processed according to timely filing provisions in the providers Absolute Total Care Participating Provider Agreement. 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. 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. Ambetter Timely Filing Limit of : 1) Initial Claims. Absolute Total Care will honor those authorizations. A. A. March 14-March 31, 2021, please send to WellCare. More Information Coronavirus (COVID-19) WellCare claims will be processed according to timely filing provisions in the providers WellCare Participating Provider Agreement. 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. To do so by phone, call Member Services at 1-888-588-9842 (TTY1-877-247-6272). As of April 1, 2021, all WellCare of South Carolina Medicaid members will transfer to Absolute Total Care. Absolute Total Care will honor those authorizations. A. Pharmacy services prior to April 1, 2021 must be requested from WellCare of South Carolina. WellCare has partnered with Change Healthcare as our preferred EDI Clearinghouse. and Human Services Please be sure to use the correct line of business prior authorization form for prior authorization requests. As of April 1, 2021, WellCare will no longer be a separate plan option offered by South Carolina Healthy Connections Choices. 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. the timely filing limits due to the provider being unaware of a beneficiary's coverage. Federal Employee Program (FEP) Federal Employee Program P.O. You can file a grievance by calling or writing to us. Please contact our Provider Services Call Center at 1-888-898-7969. Earliest From Dates on or after April 1, 2021 should be filed to 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. Q. Register now at https://www.payspanhealth.com or contact PaySpan at providersupport@payspanhealth.com, or 877-331-7154. 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. First Choice can accept claim submissions via paper or electronically (EDI). Q. For the death or injury of a member of the South Carolina National Guard, as provided for in Section 42-7-67, the time for filing a claim is two years after the accident or one year after the federal claim is finalized, whichever is later. DOS prior toApril 1, 2021: Processed by WellCare. Contact Absolute Total Care Provider Service at1-866-433-6041if youhave questions. The hearing officer will decide whether our decision was right or wrong. 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. UnitedHealthcare Dual Complete Special Needs Plan UnitedHealthcare Dual Complete Special Needs Plans (SNP) offer benefits for people with both Medicare and Medicaid. 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. Outpatient Prior Authorization Form (PDF) Inpatient Prior Authorization Form (PDF) We want you to let us know right away if you have any questions, grievances or problems with your covered services or the care you receive. For general questions about claims submissions, call Provider Claims Services at 1-800-575-0418. Providers do not need to do anything additional to provide services on or after April 1, 2021 if the provider is in network with both WellCare and Absolute Total Care. Additionally, WellCare will have a migration section on their provider page at
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