As you may know, effective July 1, 2019, the South Carolina Department of Health and
Human Services (“SCDHHS”) transitioned from the 2009 to the 2019 Medicare fee schedule
as a basis for determining Medicaid reimbursement for physicians. As part of that project,
SCDHHS announced that qualifying physicians who currently participate in the Enhanced
Physician Fee Schedule Program will be reimbursed at 129% of the base Medicaid rate for
Fee for Service (FFS) Medicaid beneficiaries.
SCDHHS has not promulgated any specific criteria regarding enhanced payments by
Managed Care Organizations (MCOs). Rather, SCDHHS has characterized the issue as a
contractual matter between the MCOs and their network providers. WellCare has elected to
enhance its Medicaid reimbursements for certain primary care physicians and has identified
you as eligible to receive these enhanced payments.
Effective for dates of service beginning December 1, 2019, WellCare will augment your
reimbursement and pay you at the rates contained in the Enhanced Physician Fee Schedule
published on SCDHHS’s website on the date the Covered Services are rendered. WellCare
reserves the right to discontinue these enhanced payments at any time. WellCare is not
making any changes to any other compensation provisions in your Agreement. If WellCare
discontinues payments based on the Enhanced Physician Fee Schedule, your rates will revert
back to the rates described in your Agreement.
Thank you for your continued participation with WellCare. We value everything you do to
deliver quality care to our members and to ensure they have a positive healthcare experience.
If you have any questions, please contact your local Provider Relations representative or call
Provider Services at 1-888-588-9842.
Frequently Asked Questions (FAQs)
1. What specialty types are eligible to receive the enhanced rates?
Providers qualifying for the program include physicians who are enrolled with WellCare
of SC as Primary Care Physicians (PCPs) with one of the following disciplines: Internal
Medicine, Family Practice, General Practice, or Pediatrics. Physicians in one of these
disciplines who are enrolled with WellCare of SC as a Specialist do not qualify.
2. Is WellCare continuing the Bill-Above Incentive Program?
No, WellCare of South Carolina’s Bill-Above Incentive Program was a temporary incentive for
select codes and will be discontinued for claims with a date of service after November 30, 2019.
3. Will WellCare reprocess claims using the new Enhanced Physician Fee
Schedule going back to July 1, 2019?
No, claims will be reimbursed at the new enhanced rates for dates of services on or after
December 1, 2019.
4. Are advanced practice providers eligible to receive the enhanced rates?
No, per SCDHHS guidelines, only physicians are eligible.
5. Do Federally Qualified Health Centers (FQHCs) qualify for enhanced rates?
No, in keeping with SCDHHS guidelines, higher payments are not available for services
that are reimbursed through a FQHC encounter rate.
6. Do Rural Health Clinics (RHCs) qualify for enhanced rates? In keeping with
SCDHHS guidelines, higher payments are not available for services that are reimbursed
through a RHC encounter rate. However, RHC providers contracted with WellCare of SC
based on SCDHHS physician fee schedule methodology and not on encounter rate
methodology are eligible.
7. Where can I find the codes and rates for the Enhanced Physician Fee Schedule?
Refer to fee schedule link below. https://www.scdhhs.gov/resource/fee-schedules.
8. Is WellCare continuing OB Enhanced Payment Program (OBEPP) ?
Yes, the OB Enhanced Payment Program will continue for physicians with a specialty of OB/GYN.
