Notice of Wellcare Material Amendment to Healthcare Contract
Date: 11/07/25
Thank you for your continued partnership with Wellcare. As you know, we are committed to continually evaluating and improving overall payment integrity solutions as required by state and federal governing entities. That’s why we have partnered with Optum to support us in performing prepayment claim reviews. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.
For claims received on or after February 15, 2026, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.
This impacts Medicare lines of business.
| Editing Area | Description |
| Trauma Activation With No Ambulance Service | This analytic will identify outpatient claims with revenue codes for trauma response (Rev 681–689) when there are no claims in history for ambulance services with HCPCS codes between A0021 and A0999 for the same member on the same date of service. |
| High-Dollar Hardware | This analytic identifies outpatient claims billing high-dollar pass-through payment for hardware with code C1713 (anchors/screw. |
| Unsupported Lab Tests on High-Dollar Claims | This analytic reviews high-dollar lab claims with at least five lines and a payment greater than $500 that are potentially unsupported by an order from a qualified healthcare professional. |
| Cross-Coder Outpatient Facility Surgical Claims | This analytic identifies outpatient facility claims with surgical procedure codes that do not match the professional claim codes for similar services provided to the same patient on the same date of service. Records will be reviewed to ensure coding/documentation guidelines are met. |
| Digital Spike Analysis | This analytic will target when a Digital Spike Analysis of EEG (95957) is billed in addition to the primary EEG procedure to verify the required additional time and extra work was done to support the billing of this code. |
| Upcoding of Incision and Drainage Codes | This analytic identifies claims billing incision and drainage (I&D) procedure codes that are suspected to be non-incision or lower-level incision and drainage that may have been incorrectly submitted to achieve additional reimbursement, reviewing simple I&D procedure codes 10060, 10080, 10140, and complicated/multiple I&D procedure codes 10061, 10081. |
| Misbilling of Third-Order Selective Catheter Placement | This algorithm targets codes for arterial selective catheter placement of the third order for placement above the diaphragm (36217) and below the diaphragm (36247) when claim details suggest that a first- or second-order arterial branch above the diaphragm or below the diaphragm was more likely the location of the procedure. Records will be reviewed to determine if the coding guidelines required to bill arterial selective catheter placement of the third order are met. |
| Cross-Coder Professional vs. Outpatient Facility Surgery Claims | This analytic identifies professional claims with surgical procedure codes that do not match the outpatient facility claim codes for similar services provided to the same patient on the same date of service. Records will be reviewed to ensure coding/documentation guidelines are met |
| Associated Code for EOP | Description |
| CPIMR | Medical Records and/or Other Service Documentation Required |
| EXbo | Medical Records and/or Other Service Documentation Required |
As a participating provider, you have options available to you if these changes are not acceptable. Please refer to Article VII in the terms and termination section of your participating provider agreement. If you have any questions, please contact our contracting team at 1-844-631-6830, or email us directly at ArkansasContracting@centene.com.