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Prepayment Clinical Validations Edit Policy (Effective 10012020)

Dear Provider,

WellCare is implementing the following policy for Prepay Code & Modifier Validation with an effective date of 10/01/2020.

Summary of policy:

In the past, certain modifiers, including but not limited to modifiers 24, 25, 59 and 79, have overridden some unbundling edits and have not been applied appropriately. Due to a high rate of incorrect usage of these modifiers, the Office of Inspector General (OIG) has advised, and CMS has implemented, prepayment review of modifiers based on the claim details and in the claim history of the patient. CMS also encourages carriers to re-examine their modifier 25 outreach activities and, where applicable, incorporate modifier 25 reviews in their prepayment review strategies. 

Consequently, WellCare will review data from the current claim and claim history to determine appropriate modifier use. The review will utilize nationally sourced guidelines. The guidelines for the correct use of overriding modifiers are well documented in Current Procedural Terminology (CPT) manuals and Coding with Modifiers manual both published by the American Medical Association (AMA), by CMS in the National Correct Coding Initiatives (NCCI) manual and the CMS claims processing manuals.

What does this mean for providers?

WellCare will enhance its existing claim editing program to improve the overall accuracy of its claims processing. As a result, WellCare wanted to share some information in advance, so providers are prepared for the upcoming modifications.

While these changes require a period of adjustment, WellCare is committed to assisting providers in order to facilitate a smooth transition. Additional information regarding the program will be available to providers during the implementation process as needed.

As always, if a provider does not agree with payment they may dispute or appeal the denial. WellCare will require medical records that substantiate the billing of the code pair and/or modifier as correct. 

Providers can review the complete policy at:, select your state, select Claims, then Payment Policy.

We are here to help. Please contact your Network Representative for general inquiries regarding this program.


WellCare Health Plans

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Last Updated On: 11/12/2020
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