04/20/2021
Dear Provider Partner,
Thank you for all of the information given to WellCare’s provider representatives on our current immunization policies. WellCare has heard you and is making several changes to its immunization reimbursement methodology.
Reimbursement Increases for Certain Immunizations
- After hearing from several providers that WellCare’s reimbursement for certain immunizations for NJ FamilyCare Plans B, C, and D children are not sufficient to cover provider acquisition costs, WellCare made the following changes to its immunization reimbursement in May 2020.
- As a result of this change, WellCare went back and reprocessed all vaccine claims with these codes with dates of service 1/1/20 and later.
- This process has been completed and all claims with these codes should be paying at the updated rates.
Revisions to WellCare’s Immunization Claim Processing: March 2021 Update
- As of 11/24/2020, WellCare is no longer denying claims where the total number of vaccine immunization units exceeds the total number of vaccine units on the claims.
- Starting in March 2021, WellCare will begin comparing the total number of VACCINE COMPONENTS of vaccines billed on a claim against number of components for that vaccine shown on the listing from the American Academy of Pediatrics. It is available at
https://www.aap.org/en-us/Documents/coding_vaccine_coding_table.pdf
- This comparison will only occur when counseling on the vaccines supplied is provided, identified by procedure codes 90460 and 90461
- If the total number of units billed for 90460 (first or only component of each vaccine) exceeds the count of vaccines billed, the entire claim will deny;
- If the total number of units billed for 90460 and 90461 exceeds the total number of vaccine components for the vaccines billed, the entire claim will deny;
- If the total number of units billed for 90460 and 90461 are less than the total number of vaccine components for the vaccines billed, the entire claim will PAY. Corrected claims can be submitted up to 365 days from the date of service.
- If counseling is not provided on the vaccines supplied, WellCare will compare the total number of units billed for procedure codes 90471, 90472, 90473 and 90474 against the count of vaccines billed.
- If the total number of units billed for 90471, 90472, 90473, and 90474 exceeds the count of vaccines billed, the entire claim will deny.
- If the total number of units billed for 90471, 90472, 90473, and 90474 are less than the count of vaccines billed, the entire claim will PAY. Corrected claims can be submitted up to 365 days from the date of service.
- Once implemented, WellCare will also apply these comparisons to claims received between 11/24/2020 and the implementation date and recover any claims that do not meet the new comparison criteria.
- Several providers expressed concerns that the list of vaccines and procedure codes identified as available from the Vaccines for Children (VFC) Program for NJ FamilyCare Plan A children was out of date.
- WellCare has made updates to the way it processes immunization claims. These updates mean that providers WILL NOT BE REQUIRED to identify VFC vaccines supplied to NJ FamilyCare Plan A children using the “SL” modifier.
- If the SL modifier is used on a claim, it should not impact WellCare’s decision to pay or deny the claim.
- WellCare will use patient identifiers submitted on immunization claims to determine whether reimbursement is appropriate for the vaccine provided.
- For reference, current VFC vaccine procedure codes and national drug codes are listed at the end of this guidance.
Reprocessing Immunization Claims Received between 8/26/19 and 2/19/20
- WellCare identified several redundancies in its immunization claim review process that resulted in inadvertent denials of valid immunization claims between the implementation of the SL modifier requirement in August 2019 and the switch to manual review of immunization claims in February 2020.
- Given this, WellCare reprocessed all immunization claims received in this period using the updated processing methodologies described above.This reprocessing was completed in September 2020.
- WellCare apologizes for any inconvenience these inadvertent denials have imposed on providers and members.
- Recovery of claims paid for VFC vaccines for NJ FamilyCare Plan A children with service dates between 3/15/19 and 8/15/20.
- Based on the updates being made to WellCare’s VFC vaccine listing, WellCare will be reviewing claims with dates of service 4/1/19 – 8/23/20 and will seek recovery on VFC vaccines supplied to NJ FamilyCare Plan A children during this period that were not previously identified as such. Notice of these recoveries was issued in January and February 2021.
- To address this concern, WellCare has updated its VFC vaccine list which is based on the current VFC Program list available from the U.S. Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html.
- Per VFC guidelines available at https://www.nj.gov/health/cd/documents/vpdp/vfc_provider_manual.pdf and New Jersey Division of Medical Assistance and Health Services (NJ FamilyCare) requirements, NJ FamilyCare Plan A children must receive vaccines from VFC supplies. Based on these requirements, WellCare will deny units billed for VFC vaccines supplied to Plan A children. The administration of these vaccines will continue to be paid at current rates.
WellCare believes these actions will bring its immunization claim payment policies in line with provider vaccine costs, vaccines currently available through the VFC program, and State vaccine reimbursement requirements.
WellCare welcomes additional feedback on these issues and looks forward to collaborating with all of our pediatric providers to ensure our members receive all appropriate immunizations in a timely manner.
Again, we thank you for your commitment to the care and wellbeing of our members, as well as to the communities we share. Please direct any additional questions or concerns on these issues to your WellCare provider representative. You can also call WellCare Provider Services at 1-888-453-2534.
Sincerely,
WellCare Health Plans of New Jersey
Provider Services: 1-888-453-2534
