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Review Criteria Change: 72 Hour Rule Enhancement

August 30, 2023

Dear Provider,
Thank you for your continued partnership with Wellcare of North Carolina. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members.

We are writing today to inform you of changes to our review criteria, as reflected in the policy below. We have removed diagnosis matching criteria in our application of this policy to better align with CMS rule changes, implemented Oct. 1, 2022.

Summary of Policy:

  • Policy Number: CC.PP.500
  • Policy Name: 3- Day Payment Window
  • Lines of Business: Medicare
  • Policy Description: The purpose of this policy is to ensure that payment for the technical component of all outpatient diagnostic services and related non-diagnostic services are bundled with the claim for an inpatient stay when services are furnished within 3 calendar days (or, with respect to a non-IPPS hospital, within 1 day) prior to and including the date of the inpatient admission. The bundling requirement does not apply to those services excluded from time to time by the health plan from this policy, such as, ambulance and outpatient maintenance renal dialysis services.

We thank you for your commitment to the care and wellbeing of our members and to the communities we serve. Should you have any questions or concerns about this notification, please contact us at Provider Services 1-855-538-0454.

Policies are posted on our website at


Wellcare of North Carolina

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Y0020_WCM_100876E Last Updated On: 8/30/2023