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Provider External Independent Third-Party Review

In accordance with 907 KAR 17:035, if you receive an adverse final decision of a denial, in whole or in part, of a health service or claim for reimbursement related to this service, you may request an external independent third-party review. You may only do so after first completing an internal appeal/dispute process with WellCare of Kentucky. Provider requests for external review will only be considered for dates of service on or after December 1, 2016.

You must submit your request for external independent third-party review within 60 days from the date of receipt of the notice. You may submit your request to WellCare of Kentucky via one of the following methods:

  1. Email: kyexternalreview@wellcare.com
  2. Fax: 1-800-509-8203
  3. Mail: WellCare Health Plans
    Attention: External Independent Third-Party Review
    13551 Triton Park Blvd. Suite 1800
    Louisville, KY 40223

WellCare will confirm receipt of your request for external third-party review within five business days of receiving your request.

As required by 907 KAR 17:035, if you request an external third-party review, WellCare will forward to the Department for Medicaid Services all documentation submitted by you during the appeal/dispute process within 15 business days of receiving your request. No additional documentation will be allowed for consideration by the external independent third-party review.

Additionally, if WellCare’s decision is upheld by the external independent third-party review, you have the right to request an administrative hearing in accordance with 907 KAR 17:040 within 30 calendar days of the Department’s written notice. You must submit your request for administrative hearing to:

Cabinet for Health and Family Services
Department for Medicaid Services
Division of Program Quality and Outcomes
275 East Main Street, 6C-C
Frankfort, KY 40621

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Last Updated On: 6/19/2018
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