Dear Provider,
WellCare Health Plans is committed to continuously improving its claims review and payment processes. Effective January 24, 2021 a significant enhancement to our physician reimbursement policies that promote correct coding. The goals of this endeavor will be implemented. It is our intent to make claim payment policies that are simple to understand and in alignment with State Medicaid Manuals. We believe that this will enable you and your billing staff to better understand our claims payment process given the widespread use of these policies.
The claims review process takes into consideration WellCare historical claims edits as well as edits from the following sources:
- State Medicaid Manuals
- CMS’ medical coding policies
- AMA CPT coding guidelines
WellCare payment policies focus on areas such as:
- Behavioral Health and Rehabilitation Services
- Children's Intervention Services
- Durable Medical Equipment and Supplies - Enteral Nutrition
- Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
- Family Planning Services – Contraceptives
- Orthotics and Prosthetics - Hearing Aids
- National Drug Code Requirements
Behavioral Health and Rehabilitation Services
Crisis Intervention Services have two main components, maximum units and modifier requirements.
Maximum Units are specific to crisis intervention services (H2011) provided in a Skilled nursing facility or a Nursing facility, as they are limited to 144 units per year when billed with the following modifier combinations:
Modifier Combinations:
- U1 (Practitioner Level 1) - U6 (In-Clinic)
- U1 (Practitioner Level 1) - U7 (Out-of-Clinic)
- U2 (Practitioner Level 2) - U6 (In-Clinic)
- U2 (Practitioner Level 2) - U7 (Out-of-Clinic)
- U3 (Practitioner Level 3) - U6 (In-Clinic)
- U3 (Practitioner Level 3) - U7 (Out-of-Clinic)
- U4 (Practitioner Level 4) - U6 (In-Clinic)
- U4 (Practitioner Level 4) - U7 (Out-of-Clinic)
According to Georgia Medicaid guidelines, crisis intervention services should be reported with modifier U6 (In-Clinic), U7 (Out-of-Clinic), or telehealth (GT) modifier. Therefore, when crisis intervention services are billed with modifier U1, U2, U3, U4 or U5 and modifier U6, U7 or GT are not also appended, the crisis intervention services (H2011) will be recommended for denial.
Children's Intervention Services
The Children's Intervention Services (CIS) Program provides coverage for restorative and rehabilitative services including audiology, health and behavior assessments, nursing services, nutrition services, occupational therapy, orthotic and prosthetic training, physical therapy and speech-language pathology.
Age Requirements
According to Georgia Medicaid guidelines, children’s intervention services must be reported with modifier HA (Child/adolescent program) and are allowed only for Medicaid eligible members less than 21 years of age.
Maximum Units Over Time
According to Georgia Medicaid guidelines, the children's intervention services reported with certain modifiers are limited to the assigned units for that modifier or modifier combination that are included in the Policies and Procedures Manual for Children's Intervention Services.
Durable Medical Equipment and Supplies - Enteral Nutrition Modifier Requirements
According to Georgia Medicaid guidelines, enteral nutrition supplies and equipment must be reported with the purchase modifier NU (New equipment). Therefore, enteral nutrition supplies are recommended for denial when billed without modifier NU.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
According to Georgia Medicaid guidelines, early and periodic screening, diagnostic and treatment (EPSDT) services should follow the recommended age requirement indicated in the American Academy of Pediatrics (AAP) and Bright Futures 'Recommendations for Pediatric Health Care' periodicity schedule. Therefore, the EPSDT service will be recommended for denial when outside of the required age recommendation:
- Infancy (Newborn – 9 months)
- Early childhood (12 months – 4 years)
- Middle childhood (5 years – 10 Years)
- Adolescence (11 years – 21 years)
Developmental Screening
According to Georgia Medicaid guidelines, developmental and/or autism screenings are allowed for patients nine months, 18 months and 30 months of age. If the screening is missed, it may be performed during a catch-up visit using modifier EP and HA or UA.
Inter-periodic and Periodic Screenings
According to Georgia Medicaid guidelines, as part of the EPSDT program, an inter-periodic hearing screening and a periodic preventive service for patients less than 21 years of age should not be reported on the same day.
EPSDT Frequency Guidelines
According to Georgia Medicaid guidelines, EPSDT services should only be billed as frequently as allowed in the Georgia Medicaid Manual, any services above and beyond this frequency will be recommended for denial.
Brief Emotional/Behavioral Assessment
According to Georgia Medicaid guidelines, a brief emotional/behavioral assessment performed during a non-periodic screening visit for a patient less than 21 years of age must be reported with modifier EP (EPSDT program) and billed in Place of Service 99 (Other).
School-Based Telemedicine Service
According to Georgia Medicaid guidelines, the telehealth originating site facility fee must be reported with modifier EP (EPSDT program) and modifier GT (Via interactive audio or video telecommunication systems) when billed in a school setting.
Family Planning Services – Contraceptives
Family Planning Services have two main components, frequency limitations and modifier requirements.
According to Georgia Medicaid guidelines, the insertion of an implantable contraceptive device and the implantable contraceptive reported as part of a Medicaid family planning program is limited to once in a three-year period.
Additionally, contraceptive injections of medroxyprogesterone acetate also known as Depo-Provera® are limited to one injection every three months.
Diaphragm fitting, condoms and contraceptive injection of medroxyprogesterone acetate must be submitted with modifier FP (Service provided as part of Medicaid family planning program). Additionally, the following implantable contraceptive devices and procedures should be reported with modifier FP (Service provided as part of Medicaid family planning program):
- Contraceptive implant
- Insertion/removal of IUD
- Removal of contraceptive implant
Orthotics and Prosthetics - Hearing Aids
According to Georgia Medicaid guidelines, hearing aid devices, items and services are not covered for patients 21 years of age or older. Additionally, monaural hearing aids, when billed, must be reported with modifier RT or LT and are limited to one unit per side in a three-year period.
National Drug Code Requirements
The National Drug Code (NDC) is a unique, three-segment number that identifies a drug. The three segments identify the labeler, the product, and the commercial package size. The NDC serves as a universal product identifier for drugs.
According to Georgia Medicaid guidelines, certain provider administered drugs must be reported with the National Drug Code (NDC) that corresponds directly to the drug related procedure code.
Examples of provider administered drugs:
- J0129 (Abatacept, Orencia ®)
- J0202 (Alemtuzumab, Lemtrada®)
- J0585 (OnabotulinumtoxinA, Botox®)
- J0894 (Decitabine, Dacogen®)
- J1300 (Eculizumab, Soliris™)
- J1743 (Idursulfase, Elaprase®)
- J9295 (Necitumumab, Portrazza®)
