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Claims and Payment Policy 148: Post-Payment Review

Summary of policy

In accordance with CMS policies and procedures, and applicable state and federal regulations, WellCare reserves the right to perform post-payment reviews to ensure payment integrity. The Kentucky Post-Payment Review Claims & Payment Policy will define WellCare’s post payment review process for providers.

What does this mean for providers?

WellCare conducts post-payment reviews of provider’s records related to services rendered to WellCare’s members. During such reviews, the provider should allow the WellCare access to, or provide, the medical record and billing documents requested that support the charges billed.

For post-payment reviews, medical records and/or related documentation will be reviewed as per the specific reason the records were requested. Upon completion of the medical record review, either the payment will stand or WellCare will issue a Recovery letter. The timeline for the requests of records is as follows:

Initial request: A letter will be mailed to the provider asking that records be provided within 30 days from the date of the letter.

Second reminder: If the requested records are not received within 30 days of the initial letter, a second letter may be mailed or outbound calls may be made to the provider, allowing the provider an additional 30 days to respond. If the records are not received by the 60th day after the initial request, the Health Plan will issue a technical denial with a request for repayment and the recoupment process will begin directly following the 60-day period for the amount stated in the letter, or per state Medicaid rules as applicable.

If the requested documentation is received after a technical denial has been issued, but within the dispute period outlined as per applicable contractual, state or federal guidelines, the records will be reviewed. If the records submitted support payment of the original claim, the review will be closed. If the records submitted do not justify payment, a findings letters with a request for payment, with appeal rights, if applicable, will be issued to the provider.

For more information, please visit our Provider section and review the complete policy found on the Claims Payment Policy page.

We are here to help. If you need further information, please contact your Network representative
at 1-800-960-2530 (TTY 711).