11/01/2014
Re: WellMed Referrals, Utilization Management and Claims Payment for Preferred Care Partners
Medicare Advantage Members in Central Florida – Effective Jan. 1, 2015
Dear Provider:
Starting Jan. 1, 2015, WellMed Medical Management, Inc. (WellMed) will handle referrals, utilization
management and claims payment for Preferred Care Partners Medicare Advantage members enrolled in the
Preferred Secure Option product available in the Central Florida counties as follows: Hernando, Hillsborough,
Manatee, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, and Volusia.
Please review the following instructions for Preferred Secure Option members in Central Florida (H1045023) for dates of service on or after Jan. 1, 2015.
Referral Management
WellMed requires a referral from the assigned primary care physician prior to rendering services for
selected specialty providers. Referrals to contracted specialists are required to be submitted through the
WellMed portal https://eprg.wellmed.net. Please see additional information on the enclosed Quick
Reference Guide and WellMed Specialty Protocol Listing for additional information.
Prior Authorization Requests
Prior Authorization requests can be submitted on the WellMed provider portal at
https://eprg.wellmed.net. You can also fax a request to 866-322-7276, or for requests that meet
Expedited classification call 877-299-7213 from 8 a.m. to 5 p.m. (EST) Monday through Friday.
Hospital Inpatient Notifications
To submit an inpatient hospital admission notification, fax notification to 877-757-8885. Notifications must be
received by WellMed no later than the first business day following the admission.
Claims Submission
For dates of service on and after Jan. 1, 2015, submit claims to WellMed as follows:
Paper Claims
Electronic Claims
Mail to: WellMed Claims
Payer ID: WELM2
P.O. Box 400066
San Antonio, TX 78229
For dates of service prior to Jan. 1, 2015 continue to send to Preferred as follows:
Paper Claims
Electronic Claims
Mail to: Preferred Care Partners
Payer ID: 65088
P.O. Box 56-5790
Miami, FL 33256-5790
The enclosed Quick Reference Guide provides more details about this change. In addition, we have included
a copy of the prior authorization list and specialty protocol listing for referrals as well. WellMed will be
conducting Webex training sessions throughout November and December, times and dates are included in
the QRG. If you have questions, please call Preferred Care Partners at 1-877-670-8432.
Thank you.
Sincerely,
Network Management Services
Quick Reference Guide
Referrals, Utilization Management, and Claims Payment for
Preferred Secure Option
Effective January 1, 2015 WellMed Network of Florida, Inc. and WellMed Medical Management, Inc (WellMed) will
handle referrals, utilization management and claims payment for Preferred Care Partners Medicare Advantage
members enrolled in the Preferred Secure Option product available in the Central Florida counties as follows:
Hernando, Hillsborough, Manatee, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, and Volusia.
Member Identification
Q1. How will I be able to recognize Preferred Secure Option members?
The ID card will indicate Preferred Secure Option (HMO) in the bottom right corner on the front of the ID card. The
Preferred Care Partners logo and member’s assigned primary care physician are also indicated on the front of the
member identification (ID) card. WellMed is indicated on the bottom right corner of the ID and the WellMed payor
ID is listed as well.
Please ensure that you are billing with the Member ID found on the Member ID Card or the claim will not be
processed.
Always verify eligibility and benefits before providing services by:


Checking online at mypreferredprovider.com, or
Calling the number on the back of the member ID card, 1-800-587-5114, which connects you to
Preferred Care Partners Benefits & Eligibility Department
Q2. Where can members call if they have a question in regards to Primary Care Physician assignment or any
other related matter?
A. Members can contact Preferred Care Partners Customer Service at 1-866-231-7201
Referral for Specialty Care
Q3. What is changing about the referral requirements for Preferred Secure Option member?
A. WellMed administers a referral program consistant with enabling the Primary Care Physician to be the gatekeeper
of a member’s healthcare. A referral is the process of sending a patient from one practitioner to another for health
care services. Except for urgent and emergent services, before a specialist treats a Preferred Secure Options
member they are required to obtain a referral from a patients PCP. The WellMed Specialty Protocol, enclosed,
will give you more information about which specialties/services may be exempt from the referral process. The
referral is put in by the assigned Primary Care Physician via the WellMed provider portal (located on the back of
the member’s ID card). The specialist is required to have a referral on file prior to claims payment.
There are two types of referrals that a PCP can issue:
1. *Evaluate Only: This type of referral gives permission to the specialist to evaluate the patient including
2.
a small list of ancillary codes. These codes are specified on the WellMed Specialty Protocol document.
*Evaluate and Manage: This type of referral gives permission to the specialist to evaluate and manage
the patient for any and all services not included on the WellMed Prior Authorization List. This type of
referral also allows the specialist the ability contact WellMed for a Prior Authorization without having
to request it through the primary care physician directly.
Please ensure that your office has a referral documented in the WellMed provider portal prior to rendering service to a
Preferred Secure Option member.
Notifications and Prior Authorizations
Q4. How do I submit a prior authorization or notification request?
A. Prior authorization requests and notifications for a Preferred Secure Option member for all services on or after
Jan. 1, 2015 should be submitted directly to WellMed. We have enclosed a copy of the Prior Authorization List
that is applicable to this product.
Prior authorization requests can be submitted on the WellMed provider portal at https://eprg.wellmed.net.
You can also fax a request to 866-322-7276, or for requests that meet Expedited classification call 877-2997213 from 8 a.m. to 5 p.m. (EST) Monday through Friday.
To submit an inpatient hospital admission notification for admission dates on or after Jan. 1, 2015, fax
notification to 877-757-8885. Notifications must be received by WellMed no later than the first business day
following the admission.
Expedited Prior Authorization requests will be handled within 24-72 hours. An answering service will take
messages or transfer to our on-call nurse during holidays and weekends. Messages will be returned within 24
hours.
Claims Submission and Reimbursement
Q5. Where do I submit claims?
A. Please submit claims for Preferred Secure Option members directly to WellMed.
For dates of service on and after Jan. 1, 2015, submit claims to WellMed as follows:
Paper Claims
Electronic Claims
Mail to: WellMed Claims
Payer ID: WELM2
P.O. Box 400066
San Antonio, TX 78229
For dates of service prior to Jan. 1, 2015, continue to send to Preferred as follows:
Paper Claims
Electronic Claims
Mail to: Preferred Care Partners
Payer ID: 65088
P.O. Box 56-5790
Miami, FL 33256-5790
Q6. What if I accidentally submit a WellMed claim to Preferred Care Partners?
A. If you submit a claim to Preferred Care Partners in error, the claim will be be denied indicating to resubmit to
the correct address. You will receive a claim status message from Preferred indicating you have submitted to the
wrong payer. It will then be the responsibility of the provider to resubmit the claim to WellMed.
Claims Status
Q7. Where can I view claims status or payment details?
A. For dates of service on or after Jan. 1, 2015, view the status of a claim or the date of payment, log in to
https://eprg.wellmed.net and click on Member Inquiry, Search Claims for the Claims Lookup. To sign up for
access, click on Create a New Account and follow the prompts.
For dates of service prior to Jan. 1, 2015, continue to view claim status on the Preferred Care Partners Provider
Portal: https://www.mypreferredprovider.com
Q8. When can I expect payment?
A. All WellMed claims payments are processed through Emdeon, a company that provides electronic payment
management. In lieu of paper checks, Emdeon will issue payments via a virtual credit card or Electronic Funds
Transfer (EFT) along with the applicable explanation of payment. If you are already signed up for Electronic
Funds Transfer (EFT) with another payer, please add WellMed to your account through the Emdeon Payment
Manager website at emdeon.com\epayment. To sign up for EFT and/or electronic remittance advice, please
register with Emdeon at emdeon.com\epayment or call 866-506-2830, option 1, to speak with an Emdeon
representative. If you are not signed up for electronic funds transfer (EFT) please find steps for the enrollment
process below:
 Step 1: Complete the EFT enrollment form found at
http://www.emdeon.com/epayment/enrollment/enrollform.php
o You should receive an email immediately to confirm/acknowledgement of the electronic
signature.
o In about 7-10 days, a test deposit will go into the account. Email notification will be sent
when test deposits are available.
 Step 2: Validate test deposits
o After confirming your bank account, an email notification will be sent stating “you banking is
now enabled.” EFT enrollment is now complete unless there are multiple NPIs associated
with your billing.
 Step 3: Complete Emdeon payor add/change/delete authorization form to add the WELM2 payor ID
o http://www.emdeon.com/epayment/enrollment/EFTPCF.php
Q9. Where do I submit claims payment disputes?
A claim payment dispute is defined as a formal written request from a provider for reconsideration of a claim
already processed by WellMed.
All disputes of claims are to be received by WellMed.
The *Claim Reconsideration Request Form is recommended for each claim dispute submitted. The provider
should submit a copy of the EOP, and any applicable supporting documentation. If you are not aware of your
timely filing limits, please refer to your provider agreement.
Mail To:
WellMed Claims
Attn:Claims Payment Disputes
P.O. Box 400066
San Antonio, TX 78229
*The Claim Reconsideration Request Form can be found on WellMed Provider Portal in the Provider Resource
section at https://eprg.wellmed.net > Provider Resources > WellMed Florida
Payment disputes for dates of services prior to Jan. 1, 2015 should be sent to Preferred Care Partners.
Preferred Care Partners
PO Box 56-5790
Miami, FL 33256-5790
Phone: 1-866-725-9334
Fax: 1-866-725-9337
2nd Level Claim Reconsiderations
Q10. What if I still disagree with the outcome of a claim and need to submit a request for a 2nd level
reconsideration?
A. Providers may submit reconsideration request in writing to:
Mail:
Phone:
Fax:
Preferred Care Partners
Grievances and Appeals Department
P.O. Box 56-6420
Miami, FL 33256-6420
1-888-291-5721
1-866-261-1474
For more information regarding the above changes, please call Preferred Care Partners Network
Management Serivces Department at 1-877-670-8432 from 9:00am-5:00pm Monday through Friday.
WellMed will be hosting a comprehensive training, we strongly encourage your office to register and
participate in one of the trainings offered to you.
Time
Date
November 18, 2014
2:00pm- 3:15pm EST
December 9, 2014
12:00pm- 1:15pm EST
January 6, 2015
9:30am-10:45am EST
January 14, 2015
12:00pm- 1:15pm EST
To register for a session, please email [email protected]. Your email should include the following
information:
•
•
•
Which date you plan to attend
Practice/physician name and Tax ID(s)
Attendee names(s) and contact phone/fax
After registering, you will receive a reply with a link to attend the webinar.