21-759 Introducing Wellcare By Health Net’s New Medicare PPO

Date: 10/27/21

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

Our new fee-for-service direct network Medicare PPO begins January 1, 2022, in Amador and Sutter counties

Wellcare By Health Net (Health Net) directly contracting fee-for-service (FFS) providers will participate and serve Wellcare No Premium Open (PPO) members in Amador and Sutter counties, as of January 1, 2022.

Wellcare No Premium Open (PPO) members can receive professional, institutional and ancillary services through Health Net’s direct network of participating providers.

How this affects you

Membership covered under this plan will access services through Health Net’s direct network. Refer to the following list for help with common administrative processes.

Medical management and prior authorization requests

For Wellcare No Premium Open (PPO), Health Net is responsible for the medical management of direct network members. Providers are required to adhere to Health Net’s prior authorization requirements and request prior authorization.

Use these directions to access current prior authorization requirements and to submit a request:

1     Go to the Provider Portal.

2     Select Working with Health Net > Services Requiring Prior Authorization under Additional Information.

3     Select Medicare Plans under Online Prior Authorization Validation Tools.

4     If the code requires a prior authorization, click on Login Here to submit a request.

 

Referrals

If it’s necessary for your patient to receive treatment from another physician or specialist, when possible, refer the patient to a Wellcare No Premium Open (PPO) in-network physician. If your patient is referred to an out-of-network provider, the patient’s benefits are reduced and a higher out-of-pocket cost is incurred.

Claims submission

Claims payment is under the terms and conditions of the Health Net Provider Participation Agreement. You can submit claims electronically via clearinghouse or through Health Net’s provider portal.

You may also submit paper claims to the address below on the standard CMS-1500 form using correct coding to ensure prompt, correct claims processing.

Health Net of California, Inc.

Medicare Claims

PO Box 9030

Farmington, MO 63640-9030

To check the status of sent claims, log in to the provider website.

Always check eligibility

Providers must verify member eligibility before each member appointment. You can check eligibility through the:

• Provider website at provider.healthnet.com.
• Health Net Provider Services Center, 800-275-4737.

ID card

You can identify Wellcare No Premium Open (PPO) members through the information and product listed on their ID cards.  

Additional information

Providers are encouraged to access the provider portal online at provider.healthnet.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact the Provider Services Center at 800-275-4737 for help with any of the following information:

• Member eligibility and effective date.
• Claims status.
• How to submit disputes and appeals.
• How to submit a complaint about the provision of care by a provider or express concerns about provider office staff.
• How to request the removal of members for disciplinary actions.