New Payment Integrity Initiatives - Effective September 29th, 2025

Date: 07/31/25

Wellcare is strengthening its commitment to payment integrity by implementing additional prepayment claim reviews aimed at preventing overpayments due to waste or abuse.

What’s Changing?

Effective September 29th, 2025, we will begin using Optum’s Comprehensive Payment Integrity (CPI) tool to conduct enhanced prepayment reviews. These reviews will focus on identifying overutilization and billing practices that may lead to unnecessary costs.

Documentation Requirements

Providers may be asked to submit medical records and billing documentation to support billed charges. Each charge must be backed by a provider’s order and clinical documentation that supports the diagnosis and services or supplies rendered.

Submission Process

Detailed instructions will be provided for submitting requested documentation. Failure to submit may result in a technical denial, meaning the claim will be denied until the necessary information is received.

Claim Adjudication & Disputes

If a coding or payment adjustment is warranted, the claim will be adjudicated accordingly. Providers retain the right to dispute review outcomes.

Need Help or Have Questions? Reach out to us through the following channels:

1. Provider Services – Duals: 1-844-796-6811 and Non-Duals: 1-800-977-7522
2. Contact your dedicated Provider Engagement Account Manager