11/12/2026
Dear Provider,
Wellcare is providing advance notice of an upcoming Payment Integrity review related to certain non-inpatient services billed during a member’s inpatient stay.
Effective 01/01/27, the Health Plan will apply Payment Integrity review criteria to applicable claims to identify services that may overlap with an inpatient stay. The purpose of this review is to support accurate claim payment in accordance with applicable billing requirements, reimbursement guidelines, provider agreements, and Health Plan requirements.
What providers need to know
- Submit claims in accordance with applicable billing and coding requirements.
- Maintain documentation supporting services billed.
- Review applicable Health Plan reimbursement policies and provider requirements.
- Follow the existing dispute or reconsideration process if additional review of a claim determination is requested.
This notification does not change member benefits or authorization requirements.
Questions
If you have questions regarding this notification or applicable billing requirements, please contact Wellcare Provider Relations.
Thank you for your continued partnership in serving our members.
Sincerely,
Wellcare
