Is WellCare Denying Your OT/PT Claims by Mistake?

In this week’s article we wanted to discuss a couple of on-going issues that we’re seeing with WellCare claims processing. There was a system error this past week that caused a number of underpayments and there is another issue we see crop up from time to time that has a very simple fix.

First, and most importantly, we wanted to address the high number of erroneous OT/PT claims denials. Are you having trouble with OT/PT claims being denied for “No Authorization” even though you do have an active/approved authorization? You’re not alone! And, if you call them to address the issue, they probably send the claim back for processing and it gets paid correctly. What a frustrating amount of work just to get your claims paid in a timely manner; there has to be an easier way!

If this is happening to you, we may have good news. Remember when you requested authorization using that horrible EviCore website (yeah we hate it too)? EviCore gave you a valid Auth number that typically follows this format “A12345678”. You may still be using that Auth to submit claims since that would make perfect sense. What they fail to mention is that “A” number is a temporary Auth number issues by EviCore before WellCare issues their “Health Plan Number” which follows a different format. So, if you bill the temporary Auth number from EviCore, your claims will be denied most of the time. One more reason EviCore needs to be removed from the process; we (I) digress.

How do you find the “Health Plan Number” you ask? Easy, just wait about 24-48 hours after submitting the auth and search the authorizations section of your WellCare portal for your patient’s authorizations (remember to search the correct Dates) and you should find it listed there. The other option is “lookup and existing auth” on the EviCore Portal and you’ll find it there listed as the “Health Plan Number.” When using this number, you shouldn’t see any more denials for this reason.

The second thing we wanted to address was a recent system error that occurred with WellCare claims that caused some of them to be underpaid for a multiple therapy reduction. This was not supposed to happen and we have worked with WellCare to find and fix this issue. They are currently pulling reports of all claims processed since the error began and fixing them for correct payment. Their response to the issue is below and if you don’t see your claims fixed within about 2 weeks we recommend reaching out to your provider rep to check in.

“The edit for Denial Reason IH153 has been modified so that it no longer applies to members under the age of 21 for our Medicaid Lines of Business to include StayWell Medicaid, StayWell Healthy Kids, and Children’s Medical Services.

An impact report has been pulled and all impacted claims will be adjusted no later than close of business on Monday May 6.  This means that you should expect to receive payment approximately 5-7 business days later, so by 5/15.”

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