Revisions to WellCare’s Immunization Claim Processing

Dear Provider Partner,

Thank you for all of the information given to WellCare’s provider representatives on our current immunization policies. WellCare has heard you and is making several changes to its immunization reimbursement methodology.

Reimbursement Increases for Certain Immunizations

• After hearing from several providers that WellCare’s reimbursement for certain immunizations for NJ FamilyCare Plans B, C, and D children are not sufficient to cover provider acquisition costs, WellCare has made the following changes to its immunization reimbursement.

WellCare Health Plans of New Jersey Vaccine Reimbursement Changes Effective 5/9/2020 For claims with Dates of Service 1/1/2020 and Later

• Over the next several weeks, WellCare will be going back and reprocessing all vaccine claims with these codes with dates of service 1/1/20 and later.
• This reprocessing will be completed in two segments. An initial segment covering dates of service 2/1/20 has already been completed. A second reprocessing for claims with dates of service in January 2020 will occur once other changes discussed in this document are fully implemented in WellCare’s systems.

Revisions to WellCare’s Immunization Claim Processing (Effective 8/24/20)

• Several providers expressed concerns that the list of vaccines and procedure codes identified as available from the Vaccines for Children (VFC) Program for NJ FamilyCare Plan A children was out of date;
• To address this concern, WellCare has updated its VFC vaccine list to include the list included at the end of this correspondence, which is based on the current VFC Program list available from the U.S. Centers for Disease Control and Prevention (CDC) at CDC Vaccine Price List.
• Per VFC guidelines available at New Jersey Provider Manual Vaccines for Children (PDF) and New Jersey Division of Medical Assistance and Health Services (NJ FamilyCare) requirements, NJ FamilyCare Plan A children must receive vaccines from VFC supplies. Based on these requirements, WellCare will deny units billed for VFC vaccines supplied to Plan A children. The administration of these vaccines will continue to be paid at current rates.
• WellCare has made updates to the way it processes immunization claims. These updates mean that providers WILL NOT BE REQUIRED to identify VFC vaccines supplied to NJ FamilyCare Plan A children using the “SL” modifier.
• If the SL modifier is used on a claim, it should not impact WellCare’s decision to pay or deny the claim.
• WellCare will use patient identifiers submitted on immunization claims to determine whether reimbursement is appropriate for the vaccine provided.
• Going forward, WellCare will be comparing the total number of vaccine units billed on a claim (including any VFC codes billed for NJ FamilyCare Plan A children) against the total number of administration units on the same claim.
  • If the total number of vaccine administration units billed is greater than the number of vaccine service units on the same claim, the entire claim will be denied.
• For reference, current VFC vaccine procedure codes and national drug codes are listed at the end of this guidance.

Reprocessing Immunization Claims Received between 8/26/19 and 2/19/20

• WellCare identified several redundancies in its immunization claim review process that resulted in inadvertent denials of valid immunization claims between the implementation of the SL modifier requirement in August 2019 and the switch to manual review of immunization claims in February 2020.
• Given this, WellCare will be reprocessing all immunization claims received in this period using the updated processing methodologies described above and expects to have this reprocessing completed by September 30, 2020.
• WellCare apologizes for any inconvenience these inadvertent denials have imposed on its providers and our members.

• Recovery of claims paid for VFC vaccines for NJ FamilyCare Plan A children with service dates between 3/15/19 and 8/15/20.
  • Based on the updates being made to WellCare’s VFC vaccine listing, WellCare will be reviewing claims with dates of service 4/1/19 – 8/23/20 and will seek recovery on VFC vaccines supplied to NJ FamilyCare Plan A children during this period that were not previously identified as such.

WellCare believes these actions will bring its immunization claim payment policies in line with provider vaccine costs, vaccines currently available through the VFC program, and State vaccine reimbursement requirements.

WellCare welcomes additional feedback on these issues and looks forward to collaborating with all of our pediatric providers to ensure our members receive all appropriate immunizations in a timely manner.

Again, we thank you for your commitment to the care and well being of our members, as well as to the communities we share. Please direct any additional questions or concerns on these issues to your WellCare provider representative or to WellCare Provider Services at 1-888-453-2534.

Sincerely,

WellCare Health Plans of New Jersey

www.wellcare.com/New-Jersey

Provider Services: 1-888-453-2534