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Reducing Low Value Care Screenings Claims Edit Guidelines Policy

As part of our continued efforts to ensure evidence-based guidelines are used when making medical decisions, WellCare edits will be enforced to support current policies for Reducing Low Value Care Screenings. 

This policy will have the following effective dates:

  • Medicare – September 1, 2019
  • Medicaid – October 1, 2019

Recent literature suggest that low-value care is prevalent across Fee for Service (FFS) Medicare, Medicaid and commercial insurance plans.  This policy has been developed to address the use of select preventive care screenings when the risk of harm from a service outweighs its potential benefit and not supported by the medical literature.

WellCare’s policy aims to ensure that providers are utilizing preventive screenings responsibly and only for medically necessary indications.  Low Value Care is defined as services rendered with little or no clinical benefit to the patient. 

These policies will apply to all providers, including freestanding facilities that submit outpatient claims for select studies.  These screenings include tests for Colorectal Cancer and Prostate Cancer screenings.

Upon evaluation of the submitted claim, if medical necessity for advanced screenings cannot be determined, that claim will be denied and the remaining adjusted amount of the claim will be paid.  Providers will have the opportunity to submit appeal requests if they believe the screening was warranted in accordance with the terms of their contract as well as medical necessity.

We are here to help. Please feel free to contact your Provider Relations representative if you have questions or need assistance. You can also call Provider Services at 1-888-453-2534 for Medicaid or 1-855-538-0454 for Medicare.

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Last Updated On: 12/29/2020