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Wellcare

Medicare providers serving Wellcare By Allwell and Wellcare By Superior HealthPlan members can find the information and resources they need on our website. Below are sections to review and reference as you work with Medicare patients.

Wellcare By Superior HealthPlan Dual Align providers delivering Medicare covered services must be enrolled as a Medicare provider through CMS and be enrolled as a Medicaid provider through the Texas Health and Human Services Commission. Texas Medicaid provider enrollment is required for all servicing, ordering, and referring providers, in order to receive reimbursement for Medicaid covered services, which includes Medicare cost-share as well as Medicaid-only covered services for the Wellcare By Superior HealthPlan Dual Align member population.  Wellcare By Superior HealthPlan verifies a provider's Texas Medicaid enrollment when claims are received and processed, and will deny Medicare cost-share and Medicaid only covered service claims if active Texas Medicaid provider enrollment cannot be confirmed for the service date(s) submitted on the claim. Providers can visit the Texas Medicaid & Health Partnership (TMHP) website to obtain additional information and apply for Texas Medicaid provider enrollment.

Please note: If you’re a provider serving Wellcare members, provider information and resources can be found on the Wellcare website.

Wellcare By Superior HealthPlan Dual Align providers delivering Medicare covered services must be enrolled as a Medicare provider through CMS and be enrolled as a Medicaid provider through the Texas Health and Human Services Commission. Texas Medicaid provider enrollment is required for all servicing, ordering, and referring providers, in order to receive reimbursement for Medicaid covered services, which includes Medicare cost-share as well as Medicaid-only covered services for the Wellcare By Superior HealthPlan Dual Align member population.  Wellcare By Superior HealthPlan verifies a provider's Texas Medicaid enrollment when claims are received and processed, and will deny Medicare cost-share and Medicaid only covered service claims if active Texas Medicaid provider enrollment cannot be confirmed for the service date(s) submitted on the claim. Providers can visit the Texas Medicaid & Health Partnership (TMHP) website to obtain additional information and apply for Texas Medicaid provider enrollment.

If you’re interested in joining the Wellcare or Medicaid network as a participating provider, or need to add a product to your existing contract, you can visit our Network Request or Update webpage.

Please note: Providers who contract with Wellcare By Superior HealthPlan (to be part of the Duals network) will only display in the integrated Provider Directory, not in the Medicaid directory.

Credentialing forms can be found on Superior's Provider Forms webpage, under the Credentialing section. 

Providers can login to Availity Essentials to manage claims and other tasks quickly and easily, including:

  • Submitting claims
  • Checking claims status
  • Submitting authorizations
  • Checking eligibility and benefits

If your organization is new to Availity, start by registering with Availity today through the Availity Multi-Payer Portal Registration webpage.

Additional options and information on claims processes and procedures are outlined in your Provider Manual.

Providers can register for the provider portal by visiting our Secure Provider Portal.

Wellcare By Superior HealthPlan (Dual Align)

Wellcare By Allwell (HMO and HMO SNP)

To check if a service requires prior authorization, reference the online Medicare Prior Authorization tool.

Wellcare By Superior HealthPlan (Dual Align)

To check if a service requires prior authorization, reference the online Wellcare By Superior HealthPlan AIP (Dual Align) Prior Authorization tool.

Additional forms can be found on Superior's Provider Forms webpage, under the Wellcare By Allwell (HMO and HMO SNP) and Wellcare By Superior HealthPlan (Dual Align) sections. 

Wellcare By Allwell (HMO and HMO SNP)

Wellcare By Superior HealthPlan (Dual Align)

Wellcare By Allwell (HMO and HMO SNP)

Wellcare By Superior HealthPlan (Dual Align)

To view upcoming live webinar trainings and RSVP, please visit our Provider Training Calendar.

Stay updated on all Wellcare news and information by signing up for our Provider Newsflash (e-newsletter) and review all provider notices through our Provider News & Information webpage.

Special Supplemental Benefits for the Chronically Ill (SSBCI) can be offered to Medicare Advantage (Wellcare By Allwell and Wellcare By Superior HealthPlan) members who have one or more complex chronic conditions, are at high risk for hospitalization or adverse health outcomes and require intensive care coordination. SSBCI aims to improve overall health outcomes for the chronically ill population by addressing social needs beyond traditional medical care such as food, housing, transportation, and gaps in care. The program is designed to support individuals by offering additional services beyond standard Medicare coverage.

Members must qualify for SSBCI benefits

Members must meet all three criteria to qualify:

  1. The member must require intensive care management.
    • The member must have a history of frequent outpatient services or specialty care and/or, evidence of poor disease control or medication adherence and/or, social or behavioral factors impacting health outcomes.
  2. The member must be at high risk for unplanned hospitalization.
    • The member must have a history of frequent hospitalizations or ED visits related to the chronic condition.
  3. The member must have a documented and active diagnosis for a qualifying chronic condition.
    • The chronic condition must be life threatening or significantly limit the overall health or function of the member.

How to Determine Eligibility

Auto Eligibility Process: We utilize internal and claims data in our internal algorithm to identify members that meet the three criteria. This automatic process refreshes weekly, and links member data across time and health plans, enabling a comprehensive view of historical claims. This process includes all members enrolled in an SSBCI-eligible plan.

Manual Eligibility Process: We may not have claims data or medical records for new members early in the year. These members can go through the manual process to have a provider attest to their eligibility.

To begin the SSBCI manual eligibility process, members must schedule an in-person office visit or contact their healthcare provider to request the attestation be completed. If an office visit is required to complete the attestation, the provider will evaluate the member’s health status during the visit and determine if they meet SSBCI criteria.

Provider Instructions for SSBCI Attestation

Providers should follow these steps to complete the attestation:

  1. Visit ssbci.rrd.com.
  2. Review the eligibility criteria outlined on the site (see criteria above) and evaluate the member accordingly.
  3. Submit an attestation through the website confirming the member meets SSBCI eligibility requirements.
  4. Submit a claim from the office visit that includes the appropriate diagnosis codes indicating the member has one or more qualifying chronic conditions listed on ssbci.rrd.com.

What Happens Next?

Once the attestation is received:

  • The member will receive an approval or denial letter within 10 business days.
  • If approved, the letter will include details about the specific SSBCI benefits available and instructions on how to access them.