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Effective January 1, 2024: Claim Review Process Through Optum

Date: 10/02/23

Wellcare By Allwell is committed to continuously improving its overall payment integrity solutions to prevent overpayments due to waste or abuse. Effective January 1, 2024, Wellcare will begin performing additional pre-payment claim reviews using Optum’s Comprehensive Payment Integrity (CPI) tool.

As a result of these pre-payment claim reviews, providers may be asked for medical records and billing documents that support the charges billed. Please note the important information below:

  • Wellcare utilizes widely acknowledged national guidelines for billing practices and supports the concept of uniform billing for all payers.
  • The pre-payment claim reviews, will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs.
  • A provider’s order must be present in the medical record to support all charges, along with clinical documentation to support the diagnosis and services or supplies billed.
  • Providers will receive detailed instructions about how to submit the requested documentation.
    • Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received. 
  • If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication.
  • Providers retain their right to dispute results of reviews.  

If you have any questions, please contact Provider Services at 1-877-391-5921.