Providers

WellCare Health Plan’s Surgical Quality and Safety Management Program

Dear Provider,

WellCare Health Plan is pleased to announce the expansion of their Surgical Quality and Safety Management Program with the vendor TurningPoint. This program has been in place for Medicare since September 2019. This program is now extending to all procedures outlined in this letter for the Medicaid program effective 12/01/2020. Cases with dates of service of 12/01/2020 or later can be submitted to Turning Point for review as of 11/16/2020. This program is designed to work collaboratively with physicians, in promoting patient safety through the practice of high quality and cost-effective care for WellCare Health Plan members undergoing Musculoskeletal Surgical Procedures.

Program highlights include:

• Administrative Tools to support an efficient, user-friendly authorization process for procedures requiring precertification, in addition to recommended medical necessity determinations for procedures, which do not require precertification. Easy and efficient post-procedural documentation submission, which will be shared with WellCare to facilitate timely claims payment.
• Specialized “Peer to Peer” Engagement where a TurningPoint physician (from the same specialty) engages the provider regarding authorization requests that require additional clinical discussion to validate the clinical appropriateness of the procedure specific to the patient’s needs and current condition.
• Clinical Support Tools to assist in the tracking and monitoring of patient outcomes and education around patient risks and preventive measures to better coordinate care for the member and reduce infection rates and complications due to patient comorbidities.
• Provider Performance Incentives for providers who comply with program requirements to practice high quality, cost effective care.
• Reporting and Analytics that gives physicians and practice administrators greater visibility and transparency into their performance compared to the practice as a whole, as well as the rest of the market.
• FDA Recall Tracking and Monitoring to facilitate timely and consistent notification to the physician, patient, and to WellCare when a member has received or needs a revision surgery due to a Class I or II FDA device recall.

Prior authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to TurningPoint Healthcare Solutions, LLC. In addition, prior authorization will be required for the following surgical procedures in both inpatient and outpatient settings:

TurningPoint’s Utilization Management & Precertification Contact Information:
Web Portal Intake: http://www.myturningpoint-healthcare.com
Telephonic Intake: 1-866-533-8562
Facsimile Intake: 850-391-3229

KEY PROVISIONS:

• Emergency Related Procedures do not require authorization
• It is the responsibility of the ordering physician to obtain authorization
• Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claims.

We appreciate your support and look forward to your cooperation in assuring that WellCare Health Plan members receive high quality cost-effective care for these surgical procedures.

We will provide additional information and training opportunities as we get closer to the effective date of the program. Should you have any questions at this time, please contact the Children’s Medical Services Provider Services Line at 1-866-799-5321 or Staywell Provider Services Line at 1-866-334-7927.

Sincerely,

WellCare Health Plans, Inc.