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MLTSS: Filing Claims

Unless otherwise stated in the Provider Participation Agreement (Agreement), providers must submit claims (initial, corrected and voided) within six (6) months or 180 days from the Medicaid or primary insurance payment date, whichever is later) from the date of service. Unless prohibited by federal law or CMS, WellCare may deny payment for any claims that fail to meet WellCare’s submission requirements for clean claims, or that are received after the time limit in the Agreement for filing Clean Claims. WellCare will adjudicate MLTSS claims within 15 days of clean claim submission.

WellCare is required to adjudicate (pay or deny) claims (for MLTSS members) for MLTSS services such as: Assisted living providers, nursing facilities, special care nursing facilities, CRS providers, adult/pediatric medical day care providers, PCA and participant directed Vendor Fiscal/Employer Agent Financial Management Services (VF/EA FMS) claims within the following timeframes:

  1. HIPAA compliant electronically submitted clean claims shall be processed within fifteen (15) calendar days of receipt; and
  2. Manually submitted clean claims shall be processed within thirty (30) calendar days of receipt.
    • If the beneficiary is dually eligible; Medicare must be billed prior to Medicaid/Family Care if the service is covered by Medicare. Medicare balances may be billed to the Medicaid/Family Care MCO if the Medicare Benefit is exhausted.    
    • If the beneficiary is not enrolled in a MCO or the beneficiary’s Medicaid/Family Care eligibility lapsed and service is a Medicaid/Family Care billable service, the beneficiary may be covered by Medicaid/Family Care FFS.