Medicaid Managed Care Questions and Answers
WellCare
The KMA has presented each of the three new Managed Care Organizations hired by the state to administer the Medicaid program in Kentucky with a list of questions. The questions
presented to each of the companies is set out below. WellCare's responses to the questions are also set out as they were provided to KMA.
Appeal Rights and Policies for Claims Question: What is the appeal process?
Answer: A provider may request an appeal regarding provider payment or contractual issues
on his or her own behalf by mailing or faxing a letter of appeal with supporting documentation such as medical records to the Plan for review.
Question: Time limits on appealing a denial?
Answer: We established that a provider has 30-days to submit an appeal and we have 30-days
to process an appeal unless a provider request an extension or we request a 14-day extension.
Question: Will physicians be able to appeal a claim using a web portal?
Answer: At this point, a provider will not be able to submit an appeal via the portal. Audits and other Compliance Issues
Question: Will the Managed Care Organizations perform pre and post payment audits in
addition to audits performed by the state and other contractors?
Answer: WellCare routinely monitors for fraud waste and abuse actives regulated by the Health
Insurance Portability and Accountability Act of 1996 (HIPAA); the Federal and State laws pertaining to the Medicare and Medicaid Programs; the Medicare Anti-Kickback Statute (42 USC §1320a-7b); All other applicable Federal and State statutory, regulatory, and contracted requirements ; the False Claims Act (31 USC § 3729-3733); State-specific False Claims Acts; the Deficit Reduction Act of 2005; Medicare Improvements for Patients and Providers Act of 2008 (MIPPA); and the Prescription Drug Benefit Manual for Part D – Chapter 9.
Question: Will the Managed Care Organizations use data analysis software to identify potential
problems priory to claims payment?
Answer: WellCare uses a multi-faceted approach to prevent and detect suspected or potential
uses a combination of analytical tools, clinical expertise, investigative knowledge, internal and external referrals, on an education and awareness training program to maximize employee, business partner and downstream entity referrals. An analytical tool called ‘Payment Optimizer’ (“PO”), a fraud prevention/detection program developed by the Fair Isaac Corporation. PO uses logic and statistical probability to identify potentially questionable professional claims that warrant further review. PO “scores” these claims every morning, and the results of the review are made available to WellCare.
Bonus/Incentives
Question: Are physicians eligible for bonuses or other incentives? Yes. How will bonuses
work?
Answer: Aligning incentives with our provider partners is a core component of our strategy to
improve our HEDIS scores. Providers who demonstrate continued significant performance improvements are recognized though our pay for performance quality incentive (P4Q) programs. Our current P4Q models take the form of either “Measure Threshold Programs”, where WellCare rewards PCPs for achieving target rates for certain HEDIS measures for the members assigned to their panels, or “Bonus-for-Service Programs”, where WellCare rewards providers with an additional bonus for providing (or arranging to provide) a specified service that is aligned with a particular HEDIS measure.
When entering a new market like Kentucky, we design our P4Q program by considering the measures that are most aligned with the health priorities of our membership base, the current baseline HEDIS rates, and reasonable expectations for provider performance improvement over a multi-year period. Consistent with our objective of continuous quality improvement, we seek to gradually raise the bar on required performance for earning a bonus each year (e.g., National Medicaid 50th percentile → 75th percentile).
Question: Will the Medicaid recipients be eligible for wellness bonus and other types of
rewards, and how will that work?
Answer: Yes. The KY program is being developed, however for several years; we have
operated a program in most of our Medicaid markets that rewards members who have received timely and appropriate prenatal services with a free stroller, including double strollers for those members having twins, and even triple strollers for those having triplets.
In 2010, we enhanced our member incentive strategy by designing and implementing piloted gift card incentive programs in WellCare’s Georgia and New York Medicaid markets. These
programs focus on key preventive screenings such as: Cervical cancer screening;
Chlamydia screening; Annual dental visits;
Well child visits within the first 15 months of life; Childhood immunizations by age two; and Diabetic retinal eye exams.
complete these screenings by the required dates (as documented by their physician) are eligible to receive a gift card reward from a selection of national merchants such as:
AMC Theaters;
Bed, Bath & Beyond / Yankee Candle Company; Build-A-Bear;
Foot Locker / Champs; Justice / Limited Too; and Regal Cinemas.
The gift card rewards amounts typically range from $10 to $50, and are set in accordance with state-specific guidelines for maximum amounts of annual incentives that Medicaid members can receive. Additionally, consistent with our goal of improving the health status of the communities we serve, our list of approved merchants excludes any that sell alcohol (including restaurants), tobacco, lottery tickets or firearms.
Claims Submission
Question: It is expected that all claims will be transmitted electronically?
Answer: WellCare will receive electronic and paper claims and has an option for direct data
entry. WellCare currently receives about 10% of it claims on UB-04 or CMS-1500 claim forms, which we convert to electronic format.
Question: Will vendors/clearinghouses be able to test claims prior to final implementation? Answer: Yes, we will test claims with vendors/clearinghouses.
Question: Will a specific timeframe be established for claims processing (all electronic claims
processed within 3-5 days etc.)?
Answer: 90% of all Provider Claims for which no further written information or substantiation is
required in order to make payment are paid or denied within thirty (30) days of the date of receipt of such Claims and 99% of all Claims are processed within ninety (90) days of the date of receipt of such Claims.
Clearinghouse/Vendors
Question: Do you have a claim infrastructure that will allow your claims processing system to
“work” with Kentucky Clearinghouses and other claim submission vendors like ZirMed, McKesson, Emdeon, etc.?
Answer: WellCare has selected RelayHealth to manage electronic data interchange (EDI)
connectivity between WellCare and our providers. All other clearinghouses, practice management vendors and billing services will be expected to connect to RelayHealth http://www.relayhealth.com/. The connection is free. Some vendors or providers may also choose to utilize the free direct data entry tools such as Wellcare.com, MD-Online or AdminisTEP.com.
Co-Payments
Answer: The same copayments that are applied under the Fee for Service program will be
applied in the Managed care Program.
Coverage Policies
Question: Will the Managed Care plan have the same coverage polices currently in place with
traditional Medicaid?
Answer: Yes.
Question: Will all the coverage policies be published?
Answer: This information will be available on the provider web portal for all web registered
providers. If not registered, the information can be obtained via Customer Service.
Eligibility and Enrollee Insurance Cards
Question: Will eligibility be determined by the Managed Care Organization or by the State? Answer: Eligibility will be determined by the State.
Question: What are the eligibility requirements? Answer: Determined by the State
Question: How will assignments take place?
Answer: The State has developed an algorithm based on the following criteria:
A. Provider Network – Only MCOs which have adequate provider network and have successfully completed the readiness assessment as defined by the Department will be considered for the mass enrollment process.
B. Keeping the family together - Assign members of a family to the same MCO.
C. Continuity of Care - Preserve the family’s pre-established relationship with providers to the extent possible
D. Robust MCO Competition - equitable distribution of the participants among the MCOs
Enrollment/Credentialing
Question: How will the enrollment/credentialing process work?
Answer: Provider Relations gathers contract documentation and associated demographic data.
PR creates a PLF (Provider Load Form) in OmniFLow (electronic workflow tool) and uploads associated documents. From there the data is extracted and sent to third party (Medversant) for outreach to provider. Medversant collects credentialing application and associated
Question: Will this be outsourced to other companies? If so, who is going to handle the
enrollment and what is the expected time frame for completion of an enrollment application (10 days, etc.?)
Answer: Yes, it will be outsourced to Medversant. However, files with no response (after 14
days) will be returned to WellCare and Provider Relations will assist. The target End to End from the day the vendor receives the provider data to the configuration load is 45 days, assuming application is received within first 14 days.
Networks
Question: Do provider networks already exist?
Answer: We will continue to welcome new providers that are in good standing with Kentucky
Medicaid to our network.
Question: Are you considering leasing a network as opposed to creating one?
Answer: Providers have the option of contracting directly, through their IPA/PHO affiliations, or
through our Center Care PPO agreement.
Pre-Authorization Process
Question: What services if any, will require pre-authorization? Answer: The authorization requirements are still in process.
Question: Will pre-authorization be handled via telephone, web portal or other method(s)? Answer: Preauthorization’s will be handled via telephone, facsimile, and web portal. Processing System
Question: What claim processing system will you use?
Answer: Xcelys 6.1 (Ingenix for pricing) http://www.ingenix.com/
Question: Will the Managed Care Organizations use the same National Correct Coding
Initiative (NCCI) edits the traditional Medicaid plan was using?
Answer: WellCare utilizes the federally mandated NCCI edits as required by the Affordability
Care Act (ACA).
Question: What other pre-payment edits will be in place?
Answer: WellCare uses industry standard coding criteria and incorporates guidelines
established by CMS such as, the National Correct Coding Initiative and the National Physician Fee Schedule Database, the AMA and Specialty Society correct coding guidelines, and state specific regulation.
Reimbursement
Question: Will the Managed Care Organizations use the current Medicaid Fee Schedule or
develop new fees?
Question: Will payments be made electronically into physician bank accounts? Will this be a
requirement?
Answer: Payments can be made electronically into the bank accounts if they sign up for
Payspan (EFT).
Question: What will be their policies for Rural Health Clinics designated by Medicaid?
Answer: RHC & FQHS will be reimbursed according to the State Medicaid Fee Schedule. The
State will reimburse the difference if the rate is less than the amount paid under Kentucky’s established prospective payment system (PPS) rate for the federally certified facilities.
Remittance/Explanation of Benefits
Question: Will physicians receive the remittance of Explanation of Benefits electronically? Will
this be a requirement?
Answer: EOB's can be received electronically also, if the provider signs up for Payspan
(EFT).
Self Service Tools
Question: Will physicians have the capability to check the status of a claim through a web
portal?
Answer: Yes, registered providers can view the status of their claims.
Question: Will physicians have the ability to correct claims once they have been submitted
electronically?
Answer: Yes, the 4010 837 format has an indicator in the CLM05-3 segment (set value to 7)
