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Policy and Procedure

Does WellCare use the Center for Medicare & Medicaid Services (CMS) ICD-10 General Equivalency Maps (GEMs) crosswalks?
General Equivalency Maps (GEMs) were used along with WellCare custom clinical and coding mappings to address gaps in GEMs during the transition.   

Did WellCare's pre-authorization policy and/or guidelines for requesting pre-authorizations change with the implementation of ICD-10?
All claims are dependent upon a valid diagnosis code being submitted. WellCare has the ability to auto-adjudicate ICD-10 claims in the same manner we auto-adjudicated ICD-9 claims.

Did WellCare update medical review policies to support ICD-10?
All medical policies were reviewed for the ICD-10 transition. Providers may access WellCare's Clinical Coverage Guidelines.

What percent of claims processed and paid claims are based on ICD codes?
All claims processed and paid are based upon procedure code fee schedules or Optum Pricers. Dollar amount is driven by either the CPT, HCPC, Rev Code or DRG assigned to the claim.

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Last Updated On: 12/21/2015