Providers

WellCare Health Plan’s Surgical Quality and Safety Management Program

Dear Provider,

WellCare Health Plan is pleased to announce the expansion of their Surgical Quality and Safety Management Program with the vendor Turning Point. This program has been in place for Medicare since September 2019. This program is now extending to all procedures outlined in this letter for the Medicaid program effective December 1, 2020. Cases with dates of service of December 1, 2020 or later can be submitted to Turning Point for review as of November 16, 2020. This program is designed to work collaboratively with physicians, in promoting patient safety through the practice of high quality and cost-effective care for WellCare Health Plan members undergoing Musculoskeletal Surgical Procedures.

Program highlights include:

• Administrative Tools to support an efficient, user-friendly authorization process for procedures requiring precertification. Additionally, to recommend medical necessity determinations for procedures, which do not require precertification. Easy and efficient post-procedural documentation submission, which will be shared with WellCare to facilitate timely claims payment.
• Specialized “Peer to Peer” Engagement where a TurningPoint physician (from the same specialty) engages the provider regarding authorization requests that require additional clinical discussion to validate the clinical appropriateness of the procedure specific to the patient’s needs and current condition.
• Clinical Support Tools to assist in the tracking and monitoring of patient outcomes. Also, to educate around patient risks and preventive measures to better coordinate care for the member and reduce infection rates and complications due to patient comorbidities.
• Provider Performance Incentives for providers who comply with program requirements to practice high quality, cost effective care.
• Reporting and Analytics that give physicians and practice administrators greater visibility and transparency into their performance. This will be compared to the practice as a whole, as well as the rest of the market.
• FDA Recall Tracking and Monitoring to facilitate timely and consistent notification to the physician, patient, and to WellCare when a member has received or needs a revision surgery due to a Class I or II FDA device recall.

This correspondence serves as notice under your participating WellCare Health Plan Provider Agreement of these program changes, effective December 1, 2020. Cases with dates of service of December 1, 2020 or later can be submitted to Turning Point for review as of November 16, 2020.

The program will include the following WellCare Health Plan membership: Medicaid. Prior authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to TurningPoint Healthcare Solutions, LLC. In addition, it will be required for the following surgical procedures in both inpatient and outpatient settings

TurningPoint’s Utilization Management & Precertification Contact Information:

Web Portal Intake: TurningPoint website

Telephone Intake: 1-866-579-7423

Facsimile Intake: 1- 678-974-0421

KEY PROVISIONS:

• Emergency Related Procedures do not require authorization
• It is the responsibility of the ordering physician to obtain authorization
• Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claims
• We appreciate your support and look forward to your cooperation in assuring that WellCare Health Plan, members receive high quality cost-effective care for these surgical procedures.

We will provide additional information and training opportunities, as we get closer to the effective date of the program. Should you have any questions at this time, please contact the WellCare Health Plan Provider Services Line at 1-855-538-0454.

Sincerely,

WellCare Health Plans, Inc.