The WellCare Group of Companies is committed to continuously evaluating and improving its overall Program Integrity solutions as required by State and Federal governing entities. WellCare has recently partnered with Optum who will begin supporting us in performing pre-payment claim auditing in 2018. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.
For claims received on or after April 1, 2018, providers may experience a slight increase in written requests for medical record submission prior to payment. These requests from WellCare will come via Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings to WellCare through Optum and directly to WellCare in the event of a disagreement.
A sample medical record request letter is provided for preview. Please note that this is a sample only and the actual letters will contain Customer Service contact telephone numbers and addresses for this program as well as claims specific details regarding medical records needed.
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.
