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Medicaid - Claims & Payment Policy (#163): NICU LOC Authorization & Reimbursement Matching

May 26, 2021

WellCare is implementing the following policy for Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Matching effective July 1, 2021.

Summary of Policy:

WellCare authorizes NICU Facility Levels by assignment of an authorized revenue code(s) to a provider for the NICU room and board stay.  If a NICU Facility Level is submitted on the UB-04 claim form with a revenue code that is at a higher level of care than the revenue code authorized by WellCare, the reimbursement for the NICU claim will be at the NICU Facility Level authorized. This only impacts claims in an outlier status by reducing charges associated with the NICU level of care.

The revenue codes used in the authorization process are listed in Table 1 of the Coding & Billing section below.

Revenue Code Level 
170 NURSERY Room and Board
171 NURSERY/LEVEL 1 Room and Board
172 NURSERY/LEVEL II Room and Board
173 NURSERY/LEVEL III Room and Board
174 NURSERY/LEVEL IV Room and Board
179 NURSERY/OTHER Room and Board

What does this mean for providers?

Providers may see adjustments for claims billed at a higher level of care than the revenue code authorized.

WellCare is committed to assisting the provider during this time of adjustment. Additional information regarding the policy will be made available during the implementation process.

If Kentucky providers do not agree with WellCare’s decision, they may appeal the denial. WellCare may require medical records that substantiate provider billing.

Providers can review the complete policy found on the Claims-Payment Policy page.

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