Claims & Payment Policy – 72-Hour Rule

December 1, 2023

Thank you for your continued partnership in serving WellCare of Kentucky members.

We are aligning with Centers for Medicare and Medicaid Services (CMS) guidelines regarding the 72-hour rule. CMS’s guidelines regarding the 72-hour rule require that hospitals bundle the technical component of all outpatient diagnostic and non-diagnostic services with the claim for an inpatient stay when services are furnished in the three days preceding an inpatient admission. Non-diagnostic services are those that may be therapeutic in nature, but clinically related to the reason for a patient's admission. CMS does not apply diagnosis code matching criteria to claims for its 72-hour window rule.

Effective 02/01/24, WellCare will no longer apply diagnosis code matching criteria and provider matching will be based on provider TAX ID. These changes will apply to outpatient facility claims.

The associated policy is CC.PP.500 3-Day Payment Window. If you have any questions regarding this notice, please contact your Provider Relations Representative. Thank you again for your continued partnership in rendering quality healthcare to our members.

Sincerely,

WellCare Health Plans