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Provider Digest | Volume 179

Date: 07/16/25

Wellcare Introduces Availity Editing Services

In a continuous effort to make it easier to do business with us, Wellcare By Health Net (Wellcare) and Wellcare By Trillium Advantage (Wellcare) are introducing Availity Editing Services (AES). Starting August 16, 2025 and running through the end of 2025, Wellcare is partnering with Availity to return rejection messages on its behalf via AES messages. These messages will show in your existing workflows. AES will give you an option, but not a requirement, to edit a claim.
 
AES can identify a claim error upfront and return a message to you for correction before sending the claim on to the plan to be adjudicated. You should review edit messages for potential corrections to the suggested claim line(s). If you make updates to the claim, this may help the claim process correctly the first time, preventing errors and improving payment accuracy and claims adjudication turnaround time. If, after reviewing the message, you find it does not apply, please resubmit the claim as-is and this will allow a bypass of the edit in cases where it may not be applicable.
 
This is not intended as a new method to deny a claim, nor does it bypass or replace downstream edits. If you choose to bypass an edit, it is possible that other downstream edits will still function as normal in our claims systems. Remember to “submit” your claim regardless of your choice to edit or bypass. This action is required in order for the claim to be processed in our systems.
 
If you have a Practice Management System (PMS), you can locate your edits report within your claims workbasket or que reporting. If you submit claims via the Availity portal, any of these rejections will show on your normal reports.
 
If you submit claims via Availity, learn how to gather your reporting by joining one of Availity’s free webinars to learn additional tips for streamlining your workflow:

  • Send and Receive EDI Files – Training Demo
    • This demo shows users where/how to access reports in Availity Essentials. These reports are where users would see edits. Please note: This demo does not use the term 'AES.' However, this is the demo that shows the user how to locate the reports.
  • EDI Reporting Preferences – Training Demo
    • This demo shows users how to set up their EDI Reporting Preferences. This needs to be done first by the user’s organization’s Availity Administrator in order to access the reports in the Send and Receive EDI Files application.

If you need assistance with registering for Availity Essentials, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. ET. 

For general questions, please contact your assigned health plan Provider Engagement Administrator:

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CAHPS and HOS Provider Resource Guide and Related Resources

Wellcare has launched a series of resources to help providers navigate CAHPS® (Consumer Assessment of Healthcare Providers and Systems) and HOS (Health Outcomes Survey).

CAHPS® is an annual survey, mandated by the Centers for Medicare & Medicaid Services (CMS), that asks patients about their experiences and satisfaction with their healthcare system, including their providers.

HOS is an annual survey administered in August to a random sample of Medicare Advantage patients. The same patients are surveyed again two years later to assess change in physical and mental health status.

You'll find lots of helpful information, recommendations, and discussion tips in the below resources:

For more information on CAHPS® and HOS, please visit our websites:

Thank you for your partnership in helping our members stay healthy.

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Upcoming Clinical Documentation Improvement Webinars

Trillium, Health Net and Wellcare providers are invited to join us for discussions that include an overview of risk adjustment and how it impacts you; tips to improve documentation and coding; and tips to stay compliant with regulatory requirements.

Webinars are open to providers, non-physician providers, coders, billers and administrative staff.  

To review the webinar schedule and sign up, please visit our websites:

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Reminder: OHA Appointment Access Requirements for Trillium Medicaid Providers

To ensure access to care and improved health outcomes, Trillium Medicaid providers are contractually obligated to comply with the Oregon Health Authority access requirements. Please review the below access requirements and contact your dedicated Provider Engagement Representative if you have any questions.

OHA Appointment Access Requirements
Providers shall make Covered Services available 24 hours a day, seven (7) days a week. For after-hours care, Providers are to have an on-call physician/nurse or a messaging system advising members how to seek after-hours care.

All Providers are required to prioritize timely access for prioritized population members:

  • Pregnant women
  • Children ages birth through (5) years

Physical Health (Primary Care and Specialists) Appointment Access Standards
 Appointment Type & Access Standard

  • Emergency: Immediate or referred to an emergency department depending on the member’s condition
  • Urgent: Within 72 hours or as indicated in initial screening and in accordance with OAR 410-141-3840 (48 hours NCQA)
  • Well Care (Routine): Within 4 weeks, or as otherwise required by applicable care coordination rules including OAR 410-141-3860- 410-141-3870

Behavioral Health (Non-Specialty/Non-Priority Populations) Appointment Access Standards
 Appointment Type & Access Standard

  • Urgent Care: Within 24 hours
  • Routine Care: Assessment within seven (7) days of the request, with a second appointment occurring as clinically appropriate.

Specialty Behavioral Health (Priority Populations) Appointment Access Standards
Priority access order for entry per OAR 309-019-0135:

  1. Individuals who are pregnant and using substances intravenously
  2. Individuals who are pregnant
  3. Individuals who are using substances intravenously; and
  4. Individuals or families with dependent children.

* If a timeframe cannot be met due to lack of capacity, the member must be placed on a waitlist and provided interim services within 72 hours of being put on a waitlist. Interim services must be provided.

Appointment Type & Access Standard

  • Urgent Care: Within 24 hours
  • Opioid use disorder: Assessment and entry within 72 hours
  • Medication assisted treatment: As quickly as possible, not to exceed 72 hours for assessment and entry
  • IV drug users including heroin: Immediate assessment and entry. Admission for treatment in a residential level of care is required within fourteen (14) days of request, or, if interim series are necessary due to capacity restrictions, admission must commence within 120 days from placement on a waitlist
  • Children with serious emotional disturbance (as defined in OAR 410-141-3500): Any limits that the Authority may specify in the contract or in sub regulatory guidance
  • Pregnant women, veterans and their families, women with children, unpaid caregivers, families, and children ages birth through five years, individuals with HIV/AIDS or tuberculosis, individuals at the risk of first episode psychosis and the I/DD population: Immediate assessment and entry. If interim services are necessary due to capacity restrictions, treatment at appropriate level of care must commence within 120 days from placement on a waitlist

* For additional information, see OAR 410-141-3840, OAR 410-141-3860, OAR 410-141-3870, and OAR 309-019-0135.

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