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Re: WellMed Referrals, Utilization Management and Claims ...

11/01/2014 Re: WellMed Referrals, Utilization Management and Claims Payment for Preferred Care Partners Medicare Advantage Members in Central Florida Effective Jan. 1, 2015 Dear Provider: Starting Jan. 1, 2015, WellMed Medical Management , Inc. ( WellMed ) will handle referrals, Utilization Management and Claims payment for Preferred Care Partners Medicare Advantage members enrolled in the Preferred Secure Option product available in the Central Florida counties as follows: Hernando, Hillsborough, Manatee, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, and Volusia. Please review the following instructions for Preferred Secure Option members in Central Florida (H1045-023) for dates of service on or after Jan.

The enclosed Quick Reference Guide provides more details about this change. In addition, we have included a copy of the prior authorization list and specialty protocol listing for referrals as well.

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Transcription of Re: WellMed Referrals, Utilization Management and Claims ...

1 11/01/2014 Re: WellMed Referrals, Utilization Management and Claims Payment for Preferred Care Partners Medicare Advantage Members in Central Florida Effective Jan. 1, 2015 Dear Provider: Starting Jan. 1, 2015, WellMed Medical Management , Inc. ( WellMed ) will handle referrals, Utilization Management and Claims payment for Preferred Care Partners Medicare Advantage members enrolled in the Preferred Secure Option product available in the Central Florida counties as follows: Hernando, Hillsborough, Manatee, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, and Volusia. Please review the following instructions for Preferred Secure Option members in Central Florida (H1045-023) for dates of service on or after Jan.

2 1, 2015. referral Management WellMed requires a referral from the assigned primary care physician prior to rendering services for selected specialty providers. Referrals to contracted specialists are required to be submitted through the WellMed portal Please see additional information on the enclosed quick reference guide and WellMed Specialty Protocol Listing for additional information. Prior Authorization Requests Prior Authorization requests can be submitted on the WellMed provider portal at You can also fax a request to 866-322-7276, or for requests that meet Expedited classification call 877-299-7213 from 8 to 5 (EST) Monday through Friday. Hospital Inpatient Notifications To submit an inpatient hospital admission notification, fax notification to 877-757-8885.

3 Notifications must be received by WellMed no later than the first business day following the admission. Claims Submission For dates of service on and after Jan. 1, 2015, submit Claims to WellMed as follows: Paper Claims Electronic Claims Mail to: WellMed Claims Payer ID: WELM2 Box 400066 San Antonio, TX 78229 For dates of service prior to Jan. 1, 2015 continue to send to Preferred as follows: Paper Claims Electronic Claims Mail to: Preferred Care Partners Payer ID: 65088 Box 56-5790 Miami, FL 33256-5790 The enclosed quick reference guide provides more details about this change. In addition, we have included a copy of the prior authorization list and specialty protocol listing for referrals as well. WellMed will be conducting Webex training sessions throughout November and December, times and dates are included in the QRG.

4 If you have questions, please call Preferred Care Partners at 1-877-670-8432. Thank you. Sincerely, Network Management Services quick reference guide Referrals, Utilization Management , and Claims Payment for Preferred Secure Option Effective January 1, 2015 WellMed Network of Florida, Inc. and WellMed Medical Management , Inc ( WellMed ) will handle referrals, Utilization Management and Claims payment for Preferred Care Partners Medicare Advantage members enrolled in the Preferred Secure Option product available in the Central Florida counties as follows: Hernando, Hillsborough, Manatee, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, and Volusia. Member Identification Q1. How will I be able to recognize Preferred Secure Option members?

5 The ID card will indicate Preferred Secure Option (HMO) in the bottom right corner on the front of the ID card. The Preferred Care Partners logo and member s assigned primary care physician are also indicated on the front of the member identification (ID) card. WellMed is indicated on the bottom right corner of the ID and the WellMed payor ID is listed as well. Please ensure that you are billing with the Member ID found on the Member ID Card or the claim will not be processed. Always verify eligibility and benefits before providing services by: Checking online at , or Calling the number on the back of the member ID card, 1-800-587-5114, which connects you to Preferred Care Partners Benefits & Eligibility Department Q2. Where can members call if they have a question in regards to Primary Care Physician assignment or any other related matter?

6 A. Members can contact Preferred Care Partners Customer Service at 1-866-231-7201 referral for Specialty Care Q3. What is changing about the referral requirements for Preferred Secure Option member? A. WellMed administers a referral program consistant with enabling the Primary Care Physician to be the gatekeeper of a member s healthcare. A referral is the process of sending a patient from one practitioner to another for health care services. Except for urgent and emergent services, before a specialist treats a Preferred Secure Options member they are required to obtain a referral from a patients PCP. The WellMed Specialty Protocol, enclosed, will give you more information about which specialties/services may be exempt from the referral process.

7 The referral is put in by the assigned Primary Care Physician via the WellMed provider portal (located on the back of the member s ID card). The specialist is required to have a referral on file prior to Claims payment. There are two types of referrals that a PCP can issue: 1. *Evaluate Only: This type of referral gives permission to the specialist to evaluate the patient including a small list of ancillary codes. These codes are specified on the WellMed Specialty Protocol document. 2. *Evaluate and Manage: This type of referral gives permission to the specialist to evaluate and manage the patient for any and all services not included on the WellMed Prior Authorization List. This type of referral also allows the specialist the ability contact WellMed for a Prior Authorization without having to request it through the primary care physician directly.

8 Please ensure that your office has a referral documented in the WellMed provider portal prior to rendering service to a Preferred Secure Option member. Notifications and Prior Authorizations Q4. How do I submit a prior authorization or notification request? A. Prior authorization requests and notifications for a Preferred Secure Option member for all services on or after Jan. 1, 2015 should be submitted directly to WellMed . We have enclosed a copy of the Prior Authorization List that is applicable to this product. Prior authorization requests can be submitted on the WellMed provider portal at You can also fax a request to 866-322-7276, or for requests that meet Expedited classification call 877-299-7213 from 8 to 5 (EST) Monday through Friday.

9 To submit an inpatient hospital admission notification for admission dates on or after Jan. 1, 2015, fax notification to 877-757-8885. Notifications must be received by WellMed no later than the first business day following the admission. Expedited Prior Authorization requests will be handled within 24-72 hours. An answering service will take messages or transfer to our on-call nurse during holidays and weekends. Messages will be returned within 24 hours. Claims Submission and Reimbursement Q5. Where do I submit Claims ? A. Please submit Claims for Preferred Secure Option members directly to WellMed . For dates of service on and after Jan. 1, 2015, submit Claims to WellMed as follows: Paper Claims Electronic Claims Mail to: WellMed Claims Payer ID: WELM2 Box 400066 San Antonio, TX 78229 For dates of service prior to Jan.

10 1, 2015, continue to send to Preferred as follows: Paper Claims Electronic Claims Mail to: Preferred Care Partners Payer ID: 65088 Box 56-5790 Miami, FL 33256-5790 Q6. What if I accidentally submit a WellMed claim to Preferred Care Partners? A. If you submit a claim to Preferred Care Partners in error, the claim will be be denied indicating to resubmit to the correct address. You will receive a claim status message from Preferred indicating you have submitted to the wrong payer. It will then be the responsibility of the provider to resubmit the claim to WellMed . Claims Status Q7. Where can I view Claims status or payment details? A. For dates of service on or after Jan. 1, 2015, view the status of a claim or the date of payment, log in to and click on Member Inquiry, Search Claims for the Claims Lookup.


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