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Peer-to-Peer Review Request Requirement Changes Effective November 1, 2022

August 1, 2022

Dear Valued Provider,

To reduce administrative burden on our provider partners, Wellcare is making the following changes to our peer-to-peer review request requirements. This will impact peer-to-peer requests received on or after November 1, 2022.

Peer-to-Peer Review Requests:

In order to ensure accurate delivery and reimbursement for medically necessary services to our members, Wellcare is updating our requirements for peer-to-peer review to the following:

  • Peer-to-peer review requests will be allowed up to two (2) business days after Integrated Denial Notice or day of discharge, whichever is later.
  • Peer-to-peer outreach will be completed within 2 business days of peer-to-peer review request.
  • If provider is not reached, a voice mail will be left (if possible) giving provider one business day to respond.
  • If the provider does not respond within the stipulated timeframe, Wellcare will be unable to proceed with peer-to-peer request.

No changes are being made to existing peer-to-peer timeframes or processes for pre-service requests.

Thank you for continuing to provide our Medicare members with high quality and compassionate care. If you have questions about any of this information, please contact Provider Services.

Sincerely,

Wellcare

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Y0020_WCM_87476E Last Updated On: 11/17/2022