Notification of Change to Outpatient Claim Submission Requirements

February 23, 2022

Summary:

Beginning on April 1, 2022, WellCare of Kentucky will be collaborating with Equian (dba Optum) to ensure consistency in claims review and reimbursement practices with our hospital partners by reviewing all outpatient facility claims that exceed outlier thresholds.     

Effective April 1, 2022, WellCare of Kentucky will require submission of itemized bills with all outpatient facility claims with billed charges exceeding $200,000.00.  You must submit an itemized detail listing each supply and service provided to the patient and match the billed charge amount for the underlying claim.

Itemized Bill Requirements:

• The itemized bill must list each supply and services provided to the member, match the dollar amount and date of service of the request.
• The request will apply to claims submitted with other insurance, changes in coverage, lapse in coverage, or if the member’s coverage termed during the length of stay.   

What happens if the claim does not meet the requirements?

If the itemized bill is not included with the claim, the claim will result in a denial requesting the itemized bill.    

How will Equian communicate its findings?

If Equian identifies any billing issues during its review, it will send you detailed findings regarding these issues and provide you with a direct contact with whom you can discuss and resolve any issues you may have with its findings.  You can also exercise your right to formally appeal Equian’s finding.

Please send all formal appeal correspondence by fax, mail or email directly to Equian at:

Equian

Attn: Appeals Department

600 12th Street, Suite 300

Golden, CO 80401

Email: reconsiderations@equian.com

Fax: 866-700-5769

Questions:

If you have questions about this communication, please contact your local provider relations representative.