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Claims & Payment Policy 152: Prepayment Clinical Validation

Dear Provider,

WellCare is implementing the following policy for Prepayment Clinical Validation: CPP-152 with an effective date as of the date of this letter.

Summary of policy:

In the past, certain modifiers, including but not limited to modifiers 25, 59, 79, 24, have overridden some unbundling edits and have not been applied appropriately. Due to a high rate of incorrect usage of these modifiers, the Office of Inspector General (OIG) has advised, and CMS has implemented, prepayment review of modifiers based on the claim details and in the claim history of the patient. CMS also encourages carriers to reexamine their modifier 25 outreach activities and, where applicable, incorporate modifier 25 reviews in their prepayment review strategies.

Consequently, WellCare and its vendor Cotiviti will review data from the current claim and claim history to determine appropriate modifier use. The review will utilize nationally sourced guidelines. The guidelines for the correct use of overriding modifiers are well documented in Current Procedural Terminology (CPT) manuals and Coding with Modifiers manual both published by the American Medical Association (AMA), by CMS in the Correct Coding Initiatives (CCI) manual and the CMS claims processing manuals.

What does this mean for providers?

WellCare will enhance its existing claim editing program to improve the overall accuracy of our claims processing. We wanted to share some information in advance, so you are prepared for the upcoming changes.

While these changes require a period of adjustment, WellCare is committed to assisting you in adjusting to these changes. Additional information regarding the program will be made available during the implementation process.

As always, if a provider does not agree with payment they may dispute or appeal the denial. WellCare will require medical records that substantiate the billing of the code pair and/or modifier as correct. 

To review the complete policy please visit the Provider page, select Claims, then Payment Policy, then Prepayment Clinical Validation: CPP-152.

We are here to help. Please contact your Network Representative for general inquiries regarding this program.