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Claims and Payment Policy: Review of NOS, NEC, & Unlisted Codes

Dear Provider,

WellCare is implementing the following policy for Review of NOS, NEC, and Unlisted Codes effective September 1, 2020.

Summary of policy:
According to the American Medical Association (AMA), each year in the United States health care insurers process over 5 billion claims for payment. To ensure that these claims are processed in an orderly and consistent manner, standardized coding systems are essential. Such coding systems include ICD-10 CM (International Classification of Diseases, 10th Edition, Clinical Modification) for diagnosis, CPT-4 Level I (Current Procedural Terminology) for procedures, and HCPCs Level II (Healthcare Common Procedure Coding System) for ambulance services, drugs, products, supplies, and durable medical equipment.

What does this mean for providers?
Claim submissions that contain procedure codes which are Not Elsewhere Classifiable (NEC), Not Otherwise Specified (NOS), or Unlisted should not be used when a more descriptive diagnosis or procedure code representing the service provided is available. WellCare will require medical record review for claims submitted with NOS, NEC, or Unlisted procedure codes to determine if the NOS, NEC, or Unlisted procedure code is appropriate. If medical records are not received along with the claims submission for the NOS, NEC, or Unlisted codes, WellCare will deny the claim until the medical records are received. Documentation may be reviewed for proper coding, existence of a more specific code, appropriate coverage, reimbursement, allowance, and prior notification if needed. The provider will have the option to rebill with the appropriate code.

To review the complete policy please visit https://www.wellcare.com/providers, select your state, select Claims, then Payment Policy.

We are here to help. If you need further information, please contact your Provider Relations Representative.

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Last Updated On: 2/25/2021
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