1. Provider Relations Quarterly Update 2017
WellCare of Nebraska
Provider Relations
Quarterly Update 2017

2. Agenda Value Added Benefits 2018 Behavioral Health updates Claims
Adding New Providers
PCMH Program
Provider Resources
Contacts

3. Value Added Benefits 2018

4. Behavioral Health Updates
Psychological testing
Initial evaluation and psychological testing can occur on the same day
Prior authorization for psychological and neuropsychological testing is required
Case review is done by a clinical psychologist for evaluation
Outpatient psychotherapy sessions
No preauthorization and no re-authorizations required for individual, family or group psychotherapy sessions DHHS Health Plan Advisory 17-08
Peer Support
All peer support professionals will enroll with Nebraska Medicaid as Community Treatment Aides,
Medicaid requirements for peer support professionals include a state and/or national certification in peer support and enrollment under a supervising practitioner, a provider group or a provider organization. DHHS Provider Bulletin 17-20

5. Claim Denials and Rejections
A claim denial is a claim that has been adjudicated and payment or non payment will be explained on the remit

6. Claim Rejections
A claim rejection will generate a letter to the provider and the claim will not be processed. Provider will need to correct the issue causing the rejection and submit a new claim.
wellcare.com
EDI Department will be able to view the claim image and help to identify why the claim is being rejected.
NPI not matching
missing information
member information mismatch

7. Known Claims Issues

8. Adding Providers/Existing Group
Complete a WellCare roster and submit it to your Provider Relations Representative- CAQH accounts only
Complete credentialing application and provide supporting documents to PR rep
A view of what providers can find on our Secure website that requires providers to register in order to gain access.

9. Adding Providers/Existing Group Cont.
CAQH Reminders
Providers need to attest to the validity of their information every 4 months
Professional Liability Insurance must not be expiring within the next 30 days
Providers must authorize WellCare to access their CAQH
Providers must list a minimum of 5 years consecutive work history (an explanation must be provided for any gap greater than 6 months)

10. WellCare PCMH program Patient-Centered Medical Home: Program Services:
A way of organizing primary care using teamwork and technology to improve quality and patient experience, and to reduce costs.
Program Services:
PCMH assessment and recommendations
Training and coaching in transformation
Quality improvement, Process Improvement
Care management assistance
Partner in Quality with the National Committee on Quality Assurance to provide assistance with recognition applications
Practice Organization
Health Information Technology
Quality Measures
Patient Experience
Family Medicine

11. Patient Centered Medical Home
3 clinics working toward NCQA recognition for Patient- Centered Medical Home
1 clinic working toward integrating behavioral health into primary care
Margaret Buck, CCE
Senior Provider Relations Representative-PCMH
WellCare Health Plans, Inc.
Mobile:  | Office:  

12. Provider Resources www.WellCare.com Medicaid Overview & Resources
Provider Handbook
Quick Reference Guide
Provider relations contact list
Authorization look up tool
Claims
Institutional/Professional claim/encounter guides
Corrected or voided claim submission guide
CMS 1500 and UB04 submission sample
Forms
Authorization Requests
Pharmacy coverage determination/appeal

13. Pharmacy Drug Look Up Tool
Details: Maximum of 1.5 tablets per day;
Maximum dose of 15mg per day for age 6-12;
Maximum dose of 30mg per day for age 13-18

14. PR Territory List

15. Provider Relations Contact List
Michelle Hartman, Behavioral Health Provider Relations Representative
Amanda Payne, Provider Relations Representative
Kami Hudson, Sr. Provider Relations Representative
Sarah Meyer, Sr. Provider Relations Representative
Lindsey Gonzales, Provider Relations Representative
Jessica Wykert, Sr. Network Management Representative
Melissa Humphrey, Manager of Provider Relations