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

If you are unable to view PDFs, please download Adobe Reader. Obstetrician care provided by an out of network Obstetrician will be covered for pregnant members inclusive of post-partum care. Absolute Total Care will honor all existing WellCare authorization approvals that include dates of service beyond March 31, 2021. Members will need to talk to their provider right away if they want to keep seeing him/her. People of all ages can be infected. We are proud to announce that WellCare is now part of the Centene Family. (This includes your PCP or another provider.) Please use the Earliest From Date. Wellcare uses cookies. The Claim Reconsideration process is an informal claim review, and is not a substitute for an appeal of a final agency decision. Claims for services prior to April 1, 2021 should be filed to WellCare for processing. The Medicare portion of the agreement will continue to function in its entirety as applicable. #~0 I 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. You now have access to a secure, quick way to electronically settle claims. The participating provider agreement with WellCare will remain in-place after April 1, 2021. Claims Department All dates of service on or after 4/1/2021 should be filed to Absolute Total Care. For additional information, questions or concerns, please contact your local Provider Network Management Representative. Professional and Institutional Encounter EDI transactions should be submitted to WellCare of South Carolina Medicaid with Payer ID 59354. Explains rules and state, line of business and CMS-specific regulations regarding 837I EDI transactions. Or it can be made if we take too long to make a care decision. Please Explore the Site and Get To Know Us. 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. 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. B^E{h#XYQv;[ny3Hha1yx4v.sBy jWacQzyL.kHhwtQ~35!Rh#)p+sj31LcC)4*Z:IWIG@WTD- )n,! We may apply a 14 day extension to your grievance resolution. 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. That's why we provide tools and resources to help. A. If you wish to use a representative, then he or she must complete an Appointment of Representative (AOR) statement. If you request a hearing, the request must: A State Fair Hearing is a legal proceeding. Q. Earliest From Dates prior to 4/1/2021 should be filed to WellCare of South Carolina. A. \{-w{,xI202100$0*bZf ,X AayhP3pYla" e 3G& `eoT#@ *;d This manual sets forth the policies and procedures that providers participating in the Absolute Total Carenetwork are required tofollow. It will let you know we received your appeal. 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. Earliest From Dates on or after April 1, 2021 should be filed to Absolute Total Care. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Copyright 2023 Wellcare Health Plans, Inc. Box 3050 How do I determine if a professional or an outpatient bill type institutional submission should be filed to WellCare or Absolute Total Care? 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. 1096 0 obj <>stream We will review it and send you a decision letter within 30 calendar days from receiving your appeal. 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. 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. Members who are dealing with stress or anxiety can call our 24-Hour Behavioral Health Crisis Line at 1-833-207-4240 to speak with a trained professional. Exceptions to the one-year time limit: a) Medicare Cost Sharing Claims . Our fax number is 1-866-201-0657. The state has also helped to set the rules for making a grievance. If Statement Range is April 2, 2021 through April 10, 2021, please send to Absolute Total Care. Q. Earliest From Dates prior to April 1, 2021 should be filed to WellCare of South Carolina. Providers are encouraged to visit the Provider Resources webpagefor manuals, forms, and resources related to claims submission, eligibility, prior authorization, and more. South Carolina Department of Health and Human Services Division of Appeals and Hearings P.O. Contact Us Y0020_WCM_100876E Last Updated On: 10/1/2022 We're here for you. WellCare Medicaid members migrating to Absolute Total Care will be assigned to their assigned WellCare primary care provider as if the primary care provideris in network with Absolute Total Care. We want to ensure that claims are handled as efficiently as possible. If an authorization is needed, you can log in to the Secure Provider Portal at absolutetotalcare.com to submit and confirm authorizations. Symptoms are flu-like, including: Fever Coughing To avoid rejections please split the services into two separate claim submissions. Copyright 2023 Wellcare Health Plans, Inc. 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! Claims Department As of April 1, 2021, WellCare will no longer be a separate plan option offered by South Carolina Healthy Connections Choices. If at any time you need help filing one, call us. Instructions on how to submit a corrected or voided claim. $8v + Yu @bAD`K@8m.`:DPeV @l 8h} \x p`03 1z`@+`~70 G ~Ws5Puick79,4 ,O5@?O-Gr'|5Oj:v6/` WellCare and Absolute Total Care Medicare plans will continue to operate under current brands, product names and provider contracts, until further notice. 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. 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. South Carolina DEPARTMENT OF HEALTH AND HUMAN SERVICES Post Office Box 8206 Columbia, South Carolina 29202-8206 www.scdhhs.gov November 24, 2009 ALL . Please use WellCare Payor ID 14163. Pregnant members receiving care from an out-of-network Obstetrician can continue to see their current obstetrician until after the baby is born. 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. A. Members will need to talk to their provider right away if they want to keep seeing him/her. 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. Guides Filing Claims with WellCare. DOSApril 1, 2021 and after: Processed by Absolute Total Care. If an authorization is needed, you can log in to the Secure Provider Portalto submit and confirm authorizations. What will happen to my Participating Provider Agreement with WellCare after 4/1/2021? It was a smart move. Explains how to receive, load and send 834 EDI files for member information. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, sex, or disability. An authorized representative is someone you select to act on the behalf of a member to assist them through the appeals process. Q. * Username. Timely filing limits vary. We expect this process to be seamless for our valued members, and there will be no break in their coverage. Farmington, MO 63640-3821. Only you or your authorizedrepresentative can ask for a State Fair Hearing. Wellcare uses cookies. We try to make filing claims with us as easy as possible. From Date Institutional Statement Dates prior to 4/1/2021 should be filed to WellCare of South Carolina. How will credentialing/recredentialing be handled by Absolute Total Care if a provider was recently credentialed/recredentialed by WellCare? Explains rules and state, line of business and CMS-specific regulations regarding 837P EDI transactions. Claims submission, correspondence, and contact resources will stay the same for the Medicare line of business. Columbia, SC 29202-8206. A. You or your provider must call or fax us to ask for a fast appeal. Professional and Institutional Fee-For-Service EDI transactions should be submitted to WellCare of South Carolina Medicaid with Payer ID 14163. First Choice can accept claim submissions via paper or electronically (EDI). As of April 1, 2021 Absolute Total Care, a Centene company, is now the health plan for South Carolina Medicaid members. Q. Members must have Medicaid to enroll. You will have a limited time to submit additional information for a fast appeal. As of April 1, 2021, all WellCare of South Carolina Medicaid members will transfer to Absolute Total Care. A provider can act for a member in hearings with the member's written permission in advance. 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. 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? If Statement Range is April 2, 2021 through April 10, 2021, please send to Absolute Total Care. For current information, visit the Absolute Total Care website. The provider needs to contact Absolute Total Care to arrange continuing care. You will get a letter from us when any of these actions occur. You may do this in writing or in person. To write us, send mail to: You can fax it too. DOS prior to April 1, 2021: Processed by WellCare. With quality healthcare solutions, Ambetter from Absolute Total Care helps residents of South Carolina live better. Download the free version of Adobe Reader. 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. Payments mailed to providers are subject to USPS mailing timeframes. 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 April 1, 2021. Our call centers, including the nurse advice line, are currently experiencing high volume. WellCare offers participating providers EFT and ERA services at no charge through PaySpan Health. N .7$* P!70 *I;Rox3 ] LS~. Living Well Quality of Care Medicaid Managed Care Medicaid and CHIP Quality Resource Library Improvement Initiatives Performance Measurement Releases & Announcements Enrollment Strategies Continuous Eligibility Express Lane Eligibility Lawfully Residing Immigrant Children & Pregnant Women Presumptive Eligibility Home & Community Based Services We are proud to announce that WellCare is now part of the Centene Family. 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. Forgot Your Password? Welcome to Wellcare By Allwell, a Medicare Advantage plan. Please use the From Date Institutional Statement Date. 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. Electronic and Paper Claims Submissions; Institutional Claims/Encounter Guides. 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. Providers interested in joining the Absolute Total Care Provider Network should submit a request to Network Development and Contracting via email at. 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. The rules include what we must do when we get a grievance. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. WellCare of South Carolina will be known as Absolute Total Care as of April 1, 2021. A. WellCare claims will be processed according to timely filing provisions in the providers WellCare Participating Provider Agreement. Always verify timely filing requirements with the third party payor. Our health insurance programs are committed to transforming the health of the community one individual at a time. The provider needs to contact Absolute Total Care to arrange continuing care. Claims Submission, Correspondence and Contact Resources will stay the same for the Medicare line of business. 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. 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. The participating provider agreement with WellCare will remain in-place after 4/1/2021. Shop or Enroll in a Plan Frequently Asked Questions Find a Doctor Download Digital ID Card Welcome Allwell Members! Ancillary Claims Filing Reminders; ClaimsXten TM: Correct Coding Initiative Reference Guide; Inpatient Non-Reimbursable Charges/Unbundling Policy S< Instructions on how to submit a corrected or voided claim. These materials are for informational purposes only. 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. You and the person you choose to represent you must sign the AOR statement. Member Appeals (Medical, Behavioral Health, and Pharmacy): You will need Adobe Reader to open PDFs on this site. It is 30 days to 1 year and more and depends on . This person has all beneficiary rights and responsibilities during the appeal process. 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. Member Sign-In. Additionally, WellCare will have a migration section on their provider page at publishing FAQs. 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. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. To have someone represent you, you must complete an Appointment of Representative (AOR) form. Where should I submit claims for WellCare Medicaid members that transition to Absolute Total Care? Wellcare wants to ensure that claims are handled as efficiently as possible. You can ask for a State Fair Hearing after we make our appeal decision. Providers can help facilitate timely claim payment by having an understanding of our processes and requirements. 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. To do this: Be sure to ask us to continue your benefits within the 10 calendar day time frame. A. Members can continue to receive services from their current WellCare provider as long as they remain covered under WellCare. We cannot disenroll you from our plan or treat you differently. If Statement Range is March 14, 2021 through April 3, 2021, please send to WellCare. To avoid rejections please split the services into two separate claim submissions. Ambetter from Absolute Total Care - South Carolina. Q. Learn more about how were supporting members and providers. 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. Professional and Institutional Encounter EDI transactions should be submitted to WellCare of South Carolina Medicaid with Payer ID 59354. P.O. From Date Institutional Statement Dates prior to April 1, 2021 should be filed to WellCare of South Carolina. L]4(f4/pn~YTZSp-5/O*F)e~p:a6o{x8r Search for primary care providers, hospitals, pharmacies, and more! DOS prior toApril 1, 2021: Processed by WellCare. Get an annual flu shot today. You or your authorized representative will tell the hearing officer why you think we made the wrong decision. The annual flu vaccine helps prevent the flu. 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 Medicare members are not affected by this change. You may file your second level grievance review within 30 days of receiving your grievance decision letter. Wellcare uses cookies. Within five business days of getting your grievance, we will mail you a letter. A. As of April 1, 2021, all WellCare of South Carolina Medicaid members will transfer to Absolute Total Care. Learn how you can help keep yourself and others healthy. A. WellCare credentialing cycles will be shared with Absolute Total Care in order to reduce duplicative credentialing in the future. Additionally, WellCare will have a migration section on their provider webpage publishing FAQs. If you dont, we will have to deny your request. 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. At WellCare, we value everything you do to deliver quality care to our members your patients and ensure they have a positive health care experience. This manual sets forth the policies and procedures that providers participating in the Wellcare Prime network are required tofollow. WellCare of South Carolina will be known as Absolute Total Care as of April 1, 2021. Refer to your particular provider type program chapter for clarification. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. 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. Will Absolute Total Care change its name to WellCare? Claims for services on or after April 1, 2021 should be filed to Absolute Total Care for processing. We will send you another letter with our decision within 90 days or sooner. 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. However, as of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. Want to receive your payments faster to improve cash flow? Q. We expect this process to be seamless for our valued members and there will be no break in their coverage. Wellcare uses cookies. APPEALS, GRIEVANCES AND PROVIDER DISPUTES. We will continue covering your medical services during your appeal request and State Fair Hearing if all of the following are meet. From Date Institutional Statement Dates on or after April 1, 2021 should be filed to Absolute Total Care. The member will be encouraged to establish care with a new in network primary care provider/specialist prior to the end of the transition/continuity of care period to review present treatment plan and coordinate the member's medical care. State Health Plan State Claims P.O. Absolute Total Care will honor those authorizations. Q. Claims for services on or after April 1, 2021 should be filed to Absolute Total Care for processing. Here are some guides we created to help you with claims filing. Molina Healthcare of Michigan, 100 W. Big Beaver Road, Suite 600 Attn: Claims, Troy, MI 48084-5209 Or Fax to: (248) 925-1768. %PDF-1.6 % Copyright 2023 Wellcare Health Plans, Inc. 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. Date of Occurrence/DOSApril 1, 2021 and after: Processed by Absolute Total Care. 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. WellCare of South Carolina will be known as Absolute Total Care as of April 1, 2021. 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. 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 WellCare and Absolute Total Care Medicare plans will continue to operate under current brands, product names and provider contracts, until further notice. To do so by phone, call Member Services at 1-888-588-9842 (TTY1-877-247-6272). If you think you might have been exposed, contact a doctor immediately. The Medicare portion of the agreement will continue to function in its entirety as applicable. 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. Q. Box 3050 Members can continue to receive services from their current WellCare provider as long as they remain covered under WellCare. Additionally, WellCare will have a migration section on their provider page at publishing FAQs. Members will receive a 90-day transition of care period if the member is receiving ongoing care and treatment. You can file your appeal by calling or writing to us. As of April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. A. You can file a grievance by calling or writing to us. Explains rules and state, line of business and CMS-specific regulations regarding 837I EDI transactions. Contact Wellcare Prime Provider Service at1-855-735-4398if youhave questions. 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. Keep yourself informed about Coronavirus (COVID-19.) DOS April 1, 2021 and after: Processed by Absolute Total Care. Please see list of services that will require authorization during this time. Example of how to properly split claim that span the cutover date of April 1, 2021: Q. What will happen to unresolved claims prior to the membership transfer? z4M0(th`1Lf`M18c BIcJ[%4l JU2 _ s 837 Institutional Encounter 5010v Guide With the completion of this transaction, we have created a premier healthcare enterprise focused on government-sponsored healthcare programs. 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. Box 31224 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. 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. 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.