10/27/2026
Dear Provider,
Thank you for your continued partnership with Wellcare. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of changes to existing review criteria that will go into place on or after 12/01/2026.
|
Description of Changes |
Lines of Business |
|
Ineligible Member Recovery: Identifying paid Medicare claims where members were ineligible for three consecutive months per the CMS 834 eligibility file. |
Medicare
|
Claims system denial code remain ‘h2’ with a provider letter verbiage of: ‘The reason for recovery “The member was ineligible for coverage on the date of service. An overpayment of $XX will be recouped".
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.
Sincerely,
Wellcare
