Claims & Payment Policy: Non-participating Provider Reimbursement Policy
Summary of policy:
WellCare allows members to receive medically necessary services and treatment by a provider not in our network (non-participating provider) when the care cannot be provided by a network provider (participating provider). A non-participating provider is defined as a provider who has not entered into a contract agreement with WellCare HealthPlans. In order to provide structured reimbursement, WellCare will pay a percentage of Medicaid fee schedule for non-participating providers who do not have a Single Case Agreement with WellCare.
This policy applies to Medicaid claims only.
What does this mean for providers?
Effective May 1st, 2020, the percentage of Medicaid fee schedule amount that will be reimbursed is based on an agreement made with each market, which is considered reasonable and customary for that market. This reimbursement structure will apply to claims submitted in Place of Service (POS) 11, 22, and 24 only. Below is the agreed upon percentage for each market:
Florida – 90% of Medicaid Fee Schedule
Please review the complete policy for more information. Claims and Payment Policies are located on the Claims page under Payment Policies.
If you are interested in joining our network, please complete the form on the Join our Network page. A representative will then contact you to complete the process.
Thank you for continuing to provide quality care to your patients, our members.
