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Post-Payment Technical Denial Enforcement

WellCare Health Plans, Inc., supports our provider partners with quality incentive programs, quicker claims payments and dedicated local market support. Following is important information for you.

Summary of change: 

WellCare has updated its Claims and Payment Policy: Pre-Payment and Post-Payment Review (Policy Number CPP-102), which includes Technical Denial procedures. We made this policy publicly available on our website. Please share this notice with other members of your practice and office staff.

What does this mean for providers?

WellCare (or its designee) conducts post-payment reviews of provider’s records related to services rendered to WellCare members. During such reviews, the provider should allow WellCare access to, or provide the medical record and billing documents, requested that support the charges billed. For post-payment reviews, medical records and/or related documentation will be reviewed as per the specific reason the records were requested. Upon completion of the medical record review, either the payment will stand or WellCare will issue a Recovery letter.

Beginning March 22, 2019, if the records are not received by the 60th day after the initial request, WellCare will issue a technical denial with a request for repayment, and the recoupment process will begin directly following the 60-day period for the amount stated in the letter, or per state Medicaid rules as applicable. A technical denial is a denial of the entire paid amount of a claim in instances when the care provided to a member cannot be substantiated due to a provider’s non-response to WellCare’s requests for medical records, itemized bills, documents, etc.

Why is WellCare implementing this policy?

As defined by CMS, medical review is the collection of information and clinical review of medical records by to ensure that payments are made only for services that meet all Medicare coverage, coding, and medical necessity requirements. The goal of WellCare’s medical review program is to increase the payment accuracy of Medicare and Medicaid claims.

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Last Updated On: 2/22/2019
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