Network Engagement Hot Topics
Health care is a dynamic industry and Wellmark is an equally dynamic company. To keep you updated on the most important changes that affect you, please check this page regularly.
Hot topics for May include:
Rate change request
Since the Affordable Care Act (ACA) went into effect, more people and more services are covered. While our members are receiving the health care services they need — which is what health insurance is for — the claims have been much higher than expected. To cover the costs of services for our members with individual and family plans, Wellmark has requested to increase rates beginning Jan. 1, 2016. The Iowa Insurance Division is currently reviewing that request. We know you are an advocate for your patients’ health, and we know your patients often turn to you with questions regarding health insurance. So you have an understanding of the reasons for this requested rate increase, and to help you educate your patients, we have created an easy-to-understand resource on the secure side of Wellmark.com.
Knowledge is power: Learn the difference between colonoscopy services
Do you know the difference between a screening (preventive) and diagnostic colonoscopy? Wellmark understands knowing the difference between colonoscopy services can be confusing. That’s why we’ve updated our language in the Outpatient Services Provider Guide to help. Check out the updated provider guide today to learn more.
Clarification on air ambulance claims filing changes
For dates of service on and after April 19, 2015, air ambulance providers are now required to file air ambulance claims based on pick up zip code. Previously, claims were filed to the plan based on where the air ambulance was headquartered. The Blue Cross and Blue Shield Association (BCBSA) claims filing change impacts providers who are ‘third parties’ or vendors that submit claims on a CMS-1500 claim form, separate from the facility. This BCBSA change does not impact air ambulance services billed under the hospital’s tax identification (ID) and national provider identifier (NPI). For more information, refer to the General Medical Provider Guide.
Do you prescribe Flonase to your patients?
Beginning May 15, 2015, Wellmark will no longer cover Flonase as a pharmacy benefit due to an over-the-counter (OTC) version being made available. Members can now purchase OTC Flonase at most retail stores and pharmacies without a prescription. Please work with your patients to encourage them to use the OTC Flonase.
Reimbursement for breast pumps changing
Given provider feedback, the reimbursement methodology for breast pumps changed July 1, 2014. The reimbursement transitioned from the fee schedule to 60 percent of the manufacturer’s suggested retail price (MSRP) or 120 percent of invoice. Effective July 1, 2015, reimbursement will switch to 50 percent of MSRP or 120 percent of invoice. Upgrade and non-covered charges are taken into consideration when priced using this updated payment methodology and should not be submitted separately or billed to the member. To facilitate accurate reimbursement, please submit a paper claim and accompanying manufacturer’s retail statement price or invoice to avoid claim denials. For more information, refer to the HME, Orthotics, and Prostheses Provider Guide.
Learn more about Enhanced Ambulatory Patient Groupings (EAPGs)
Become the expert in your organization by registering for the May 13th webinar on “Understanding EAPG Payments.” During this webinar you will learn what you can expect with EAPG payments, as well as the resources made available. The webinar will also walk through some hypothetical examples to give you a greater understanding on EAPG claims processing. Register today to learn more!
Go paperless for faster receipt of payments
If you have not enrolled in electronic fund transfer (EFT), now is the time. EFT is a method by which Wellmark electronically reimburses providers for their claims. By signing up for EFT, you will be able to receive payments faster and eliminate the clutter of paper checks. You will also have the ability to match the payment to your provider claim remittance (PCR) sooner! To sign up or change enrollment, use our Electronic Funds Transfer (EFT) Form. Please note, you must have secure access to Wellmark.com in order to submit the form. If you have any questions, check out our Frequently Asked Questions document. Enroll today!
Submit secondary claims electronically
Did you know that you can file secondary claims to Wellmark electronically? By submitting secondary claims electronically, it will not only allow Wellmark to receive the claim quicker, but you will receive an 835 (electronic remittance advice) for tracking purposes. Better yet, the status of your claim is viewable on Wellmark.com in just 24-48 hours after acceptance! Once you have received payment from the primary payer, submit your claim either by using Wellmark’s Create and Submit a Claim tool or your electronic claims vendor for faster turn-around time. For instructions and more information on submitting secondary claims electronically, refer to the Claims Filing Provider Guide.