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

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. Additionally, WellCare will have a migration section on their provider page at publishing FAQs. Electronic and Paper Claims Submissions; Institutional Claims/Encounter Guides. WellCare offers participating providers EFT and ERA services at no charge through PaySpan Health. Member Appeals (Medical, Behavioral Health, and Pharmacy): You will need Adobe Reader to open PDFs on this site. To continue providing transition of care services, providers that are not part of the Absolute Total Care Network must agree to work with Absolute Total Care and accept Absolute Total Cares payment rates. This manual sets forth the policies and procedures that providers participating in the Wellcare Prime network are required to follow. If you file a grievance or an appeal, we must be fair. For dates of service on or after April 1, 2021: Absolute Total Care 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. Q: What is Absolute Total Cares Transition/Continuity of Care Policy? What will happen to unresolved claims prior to the membership transfer? 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. South Carolina DEPARTMENT OF HEALTH AND HUMAN SERVICES Post Office Box 8206 Columbia, South Carolina 29202-8206 www.scdhhs.gov November 24, 2009 ALL . This manual sets forth the policies and procedures that providers participating in the Absolute Total Carenetwork are required tofollow. A provider can act for a member in hearings with the member's written permission in advance. If you dont, we will have to deny your request. 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. Reimbursement Policies A. Copyright 2023 Wellcare Health Plans, Inc. Clinical Laboratory Improvement Amendments (CLIA). Earliest From Dates prior to April 1, 2021 should be filed to WellCare of South Carolina. N .7$* P!70 *I;Rox3 ] LS~. Q. Call us to get this form. Here are some guides we created to help you with claims filing. Providers can help facilitate timely claim payment by having an understanding of our processes and requirements. To do this: Be sure to ask us to continue your benefits within the 10 calendar day time frame. 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. As of April 1, 2021, WellCare will no longer be a separate plan option offered by South Carolina Healthy Connections Choices. Send your written appeal to: We must have your written consent before someone can file an appeal for you. The second level review will follow the same process and procedure outlined for the initial review. For additional information, questions or concerns, please contact your local Provider Network Management Representative. 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. A. 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. Q. The rules include what we must do when we get a grievance. A. Download the free version of Adobe Reader. P.O. Members will receive a 90-day transition of care period if the member is receiving ongoing care and treatment. 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. Check out the Interoperability Page to learn more. A. Finding a doctor is quick and easy. What is the Rx BIN and Group Number for WellCare members transitioning to Absolute Total Care on April 1, 2021? $8v + Yu @bAD`K@8m.`:DPeV @l 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. First Choice can accept claim submissions via paper or electronically (EDI). pst/!+ Y^Ynwb7tw,eI^ In South Carolina, WellCare and Absolute Total Care are joining to better serve you. Hearings are used when you were denied a service or only part of the service was approved. Please use the Earliest From Date. Molina Healthcare of Michigan, 100 W. Big Beaver Road, Suite 600 Attn: Claims, Troy, MI 48084-5209 Or Fax to: (248) 925-1768. Copyright 2023 Wellcare Health Plans, Inc. Will my existing WellCare patients be assigned to my Absolute Total Care Panel? We're here for you. Select Health Claims must be filed within 12 months from the date of service. Learn how you can help keep yourself and others healthy. We must have your written permission before someone can file a grievance for you. and Human Services B^E{h#XYQv;[ny3Hha1yx4v.sBy jWacQzyL.kHhwtQ~35!Rh#)p+sj31LcC)4*Z:IWIG@WTD- )n,! A. Here you will find the tools and resources you need to help manage your submission of claims and receipt of payments. March 14-March 31, 2021, please send to WellCare. All dates of service on or after April 1, 2021 should be filed to Absolute Total Care. The way your providers or others act or treat you. An authorized representative is someone you select to act on the behalf of a member to assist them through the appeals process. 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. Need an account? Know the facts about Coronavirus (COVID-19) Our call centers, including the nurse advice line, are currently experiencing high volume. Contact Wellcare Prime Provider Service at 1-855-735-4398 if you have questions. We expect this process to be seamless for our valued members, and there will be no break in their coverage. With the completion of this transaction, we have created a premier healthcare enterprise focused on government-sponsored healthcare programs. WellCare Medicare members are not affected by this change. Thanka kaa yoa Tufrbeau ingsnh ngetfu South Caralaita nouMa mpvd. Timely filing limits vary. Q. The annual flu vaccine helps prevent the flu.Protect yourself and those around you. The participating provider agreement with WellCare will remain in-place after 4/1/2021. A. (This includes your PCP or another provider.) 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. You can do this at any time during your appeal. DOS April 1, 2021 and after: Processed by Absolute Total Care. 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. Those who attend the hearing include: You can also request to have your hearing over the phone. A grievance is when you tell us about a concern you have with our plan. Earliest From Dates on or after April 1, 2021 should be filed to Absolute Total Care. Pregnant members receiving care from an out-of-network Obstetrician can continue to see their current obstetrician until after the baby is born. WellCare is the health care plan that puts you in control. North Carolina PHP Billing Guidance for Local W Code. It can also be about a provider and/or a service. Our toll-free fax number is 1-877-297-3112. These grievances may be about: The state of South Carolina allows members to file a grievance at anytime from the event that caused the dissatisfaction. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Wellcare uses cookies. Please be sure to use the correct line of business prior authorization form for prior authorization requests. Absolute Total Care will honor those authorizations. How are WellCare Medicaid member authorizations being handled after April 1, 2021? What will happen to my Participating Provider Agreement with WellCare after 4/1/2021? 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. Guides Filing Claims with WellCare. Download the free version of Adobe Reader. To avoid rejections please split the services into two separate claim submissions. Initial Claims: 120 Days from the Date of Service. How do I bill a professional submission with services spanning before and after 04/01/2021? Q. Outpatient Prior Authorization Form (PDF) Inpatient Prior Authorization Form (PDF) Only you or your authorizedrepresentative can ask for a State Fair Hearing. Synagis (RSV) - Medical Benefit or Retail Pharmacy, 17P or Makena - Medical Benefit or Retail Pharmacy, Special Supplemental Benefits for Chronically Ill (SSBCI), Screening, Brief Intervention, and Referral to Treatment (SBIRT), Patient Centered Medical Home Model (PCMH), Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), National Committee for Quality Assurance (NCQA), Hurricane Florence: What You Need to Know, Absolute Total Care Payment Policy and Edit Updates Effective 5/1/21, Notice About a New Payment Integrity Audit Program, Absolute Total Care Updated Guidance for Medicaid BabyNet Therapy Providers, Wellcare By Allwell Changing Peer-to-Peer Review Request and Elective Inpatient Prior Authorization Requirements for Medicare Advantage Plans, NEW Attestation Process for Special Supplemental Benefits for Chronically Ill (SSBCI), Medicare Prior Authorization Change Summary - Effective 1/1/2023, Shortened Notification of Pregnancy (NOP) Provider Form (PDF), Notification of Pregnancy (NOP) Provider Form (PDF), Pregnancy Incentive Reimbursement Form (PDF), SCDHHS Form 1716 - Request for Medicaid ID Number - Infant (PDF), Member Appointment of Authorized Representative Form (PDF), SCDHHS Hospice Election/Enrollment Forms (PDF), Inpatient Prior Authorization Fax Form (PDF), Outpatient Prior Authorization Fax Form (PDF), SCDHHS Certificate of Medical Necessity (CMN) for Oxygen (PDF), Sick and Well Visit Reimbursement Letter (PDF), Claim Adjustments, Reconsiderations, and Disputes Provider Education (PDF), Obstetrical (OB) Incentive Programs (PDF), Provider Portal Enhancements: Claim Reconsideration and Denial Explanations (PDF), Outpatient Prior Authorization Form (PDF), Medicare Prescription Drug Coverage Determination Form (PDF), Authorization to Use and/or Disclose Health Information (PDF), Revocation of Authorization to Use and/or Disclose Health Information (PDF), Behavioral Health Psychological or Neuropsychological Testing Authorization Request Form (PDF), Electroconvulsive Therapy (ECT) Authorization Request Form (PDF), Behavioral Health Outpatient Treatment Request Form (PDF), Transitional Care Management Services Fact Sheet (PDF), Expedited Prior Authorization Request FAQ (PDF), Balance Billing Quick Reference Guide (PDF), 2021 Prior Authorization List Part B Appendix A (PDF), Bi-Annual Prior Authorization Update (PDF), 2021 Bi-Annual Prior Authorization Update Effective 8/1/21 (PDF), 2021 List of Covered Drugs (Formulary) Changes (PDF), New Century Health Implementation Notification (PDF), 2022 Wellcare by Allwell Provider Manual (PDF), Provider Reconsideration/Dispute Form (PDF), Behavioral Health Neuropsychological Testing Authorization Request Form (PDF), Behavioral Health Outpatient Treatement Request Form (PDF), Behavioral Health Electroconvulsive Therapy (ECT) Authorization Request Form (PDF), Electronic Funds Transfer (ETF) Features (PDF), 2021 List of Covered Drugs (Formulary) DSNP Changes (PDF), 2021 List of Covered Drugs (Formulary) HMO Changes (PDF). All dates of service on or after 4/1/2021 should be filed to Absolute Total Care. Download the free version of Adobe Reader. 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. Pregnant members receiving care from an out of network Obstetrician can continue to see their current Obstetrician until after the baby is born. WellCare of North Carolina will begin to release medical payments to providers beginning July 6, 2021. You can get many of your Coronavirus-related questions answered here. Claims will be processed according to timely filing provisions in the providers Absolute Total Care Participating Provider Agreement. Tampa, FL 33631-3372. We have licensed clinicians available to speak with you and to connect you to the support you need to feel better. Claims Submission, Correspondence and Contact Resources will stay the same for the Medicare line of business. Search for primary care providers, hospitals, pharmacies, and more! By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Keep yourself informed about Coronavirus (COVID-19.) Learn more about how were supporting members and providers. 941w*)bF iLK\c;nF mhk} WellCare claims will be processed according to timely filing provisions in the providers WellCare Participating Provider Agreement. Example of how to properly split claim that span the cutover date of April 1, 2021: Q. WellCare of South Carolinawants to ensure that claims are handled as efficiently as possible. If you request a hearing, the request must: A State Fair Hearing is a legal proceeding. We welcome Brokers who share our commitment to compliance and member satisfaction. We will also send you a letter with our decision within 72 hours from receiving your appeal. For the latest COVID-19 news, visit the CDC. All billing requirements must be adher ed to by the provider in order to ensure timely processing of claims. The Medicare portion of the agreement will continue to function in its entirety as applicable. South Carolina Department of Health and Human Services Division of Appeals and Hearings P.O. A. Click below for more information from Absolute Total Care: You are now able to view your health information from a third-party app on a mobile device or PC! 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 Claims will be processed according to timely filing provisions in the providers WellCare Participating Provider Agreement. 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. Absolute Total Care 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. You and the person you choose to represent you must sign the AOR form. Claims for services on or after April 1, 2021 should be filed to Absolute Total Care for processing. WellCare of South Carolina will be known as Absolute Total Care as of April 1, 2021. You must ask within 30 calendar days of getting our decision. 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. %PDF-1.6 % If Medicare is the primary payer, timely filing is determined from the processing date indicated on the primary carrier's explanation of benefit (EOB) If Medicare is the Secondary Payer (MSP), the initial claim must be submitted to the primary payer within Cigna's timely filing period. The annual flu vaccine helps prevent the flu. Providers are encouraged to visit the Provider Resources webpageformanuals, forms, clinical policies, payment policies, provider news and resources related to claims submission, eligibility, prior authorization and more. We expect this process to be seamless for our valued members and there will be no break in their coverage. Q. The provider needs to contact Absolute Total Care to arrange continuing care. The hearing officer will decide whether our decision was right or wrong. Get an annual flu shot today. ?-}++lz;.0U(_I]:3O'~3-~%-JM WellCare and Absolute Total Care Medicare plans will continue to operate under current brands, product names and provider contracts, until further notice. We will call you with our decision if we decide you need a fast appeal. Yes, Absolute Total Care and WellCare will continue to offer Medicare products under their current brands and product names, until further notice. The benefit can be used to get more than 150 items - including vitamins, pain relievers, cold and allergy medicines, baby wipes, and diapers - at no cost . Our call centers, including the nurse advice line, are currently experiencing high volume. The onlineProvider Manual represents the most up-to-date information on Absolute Total Cares Medicaid Plan, programs, policies, and procedures. 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. Box 31384 The timely filing limit is the time duration from service rendered to patients and submitting claims to the insurance companies. Ambetter Timely Filing Limit of : 1) Initial Claims. However, there will be no members accessing/assigned to the Medicaid portion of the agreement. Your second-level review will be performed by person(s) not involved in the first review. 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. WellCare and Absolute Total Care Medicare plans will continue to operate under current brands, product names and provider contracts, until further notice. Our fax number is 1-866-201-0657. Please use WellCare Payor ID 14163. Box 31224 April 1-April 3, 2021, please send to Absolute Total Care. You may do this in writing or in person. 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. Incorrect forms will not be considered and may lead to further delays in processing prior authorization requests. More Information Coronavirus (COVID-19) Prior authorizations issued by WellCare for dates of service on or after April 1, 2021 will transfer with the members eligibility to Absolute Total Care. These materials are for informational purposes only. Please see list of services that will require authorization during this time. Claims Department The Claim Reconsideration process is an informal claim review, and is not a substitute for an appeal of a final agency decision. From Date Institutional Statement Dates on or after 4/1/2021 should be filed to Absolute Total Care. Claims will be processed according to timely filing provisions in the providers WellCare Participating Provider Agreement. However, as of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. Welcome to WellCare of South Carolina! Claims for services prior to April 1, 2021 should be filed to WellCare for processing. 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. Go365 for Humana Healthy Horizons Members can register for the new Go365 for Humana Healthy Horizons wellness program and earn rewards for participating in healthy activities. At the hearing, well explain why we made our decision. Absolute Total Care will continue to offer Marketplace products under the Ambetter brand. 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. Symptoms are flu-like, including: Fever Coughing 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. We will do this as quickly as possible as but no longer than 72-hours from the decision. A. We are proud to announce that WellCare is now part of the Centene Family. Wfu neebybfgnh bgWfulnybfgC South Carolina Medicaid Provider Resource Guide Thank you for being a star member of our provider team. You will need Adobe Reader to open PDFs on this site. Providers are encouraged to visit the Provider Resources webpagefor manuals, forms, and resources related to claims submission, eligibility, prior authorization, and more. Instructions on how to submit a corrected or voided claim. Will Absolute Total Care change its name to WellCare? You can file your appeal by calling or writing to us. Wellcare uses cookies. A. WellCare credentialing cycles will be shared with Absolute Total Care in order to reduce duplicative credentialing in the future. Members will receive a 90-day transition of care period if the member is receiving ongoing care and treatment. Timely Filing Beginning October 1, 2020, the Timely Filing submission requirements specified in each Provider's Meridian Medicare contract will be enforced. As of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. As of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. A. Claim Filing Manual - First Choice by Select Health of South Carolina 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.