5/4/2026
Dear Provider,
Thank you for your continued partnership with Wellcare of Maine. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of changes to existing review criteria that will go into place on or after 6/1/2026.
| Description of Changes | Lines of Business |
|---|---|
| Non-Exact Duplicate Facility Stay Duplicate: Recouping non-exact duplicate inpatient hospital claims that represent the same inpatient stay but were billed more than once. This initiative identifies inpatient claims for the same member, provider, and hospital with overlapping dates of service where an additional claim falls within the original inpatient stay but was billed under a different DRG or Type of Bill. The concept supports payment accuracy by ensuring that only one appropriate inpatient DRG payment is made per admission in line with CMS inpatient billing requirements. |
Marketplace Medicare Medicaid Commercial Behavioral |
Claims system denial code remain ‘h2’ with a provider letter verbiage of: ‘The reason for recovery “The member was ineligible for coverage on the date of service. An overpayment of $XX will be recouped".’
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.
Sincerely,
Wellcare of Maine
