2021-350-EMS-E-WellCare Health Plans of NC Inc-Medicaid managed care

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Page 44 of 48 (c) Resolution of Appeal. WellCare will establish a committee to review and make decisions on Provider’s appeals, which committee will consist of at least three (3) qualified individuals who were not involved in the original decision, action, or inaction giving rise to the right to appeal, as well as an external peer reviewer when the issue on appeal involves whether the provider met the Objective Quality Standards. WellCare will provide written notice of decision of the appeal (which notice shall include information regarding further appeal rights) within thirty (30) calendar days of receiving a complete appeal request, or if an extension is granted to the provider to submit additional evidence, the date on which all evidence is submitted to WellCare. Provider may be represented by an attorney during the appeals process. (d) Appeals of Suspension or Withhold of Provider Payment. In cases of the suspension or withholding of Provider payments, WellCare will limit the issue on appeal to whether WellCare had good cause to commence the withholding or suspension of payments to Provider; WellCare will not address whether Provider has or has not committed fraud or abuse. WellCare will offer Provider an in-person or telephone hearing when Provider is appealing whether WellCare has good cause to withhold or suspend payments to Provider. WellCare will schedule such hearing and issue a written decision regarding whether WellCare had good cause to suspend or withhold payments within fifteen (15) business days of receiving Provider’s appeal. Upon a finding that WellCare did not have good cause to suspend or withhold payments, WellCare will reinstate any payments that were withheld or suspended within five (5) business days. WellCare will pay interest and penalties for overturned denials, underpayments, or findings that it did not have good cause to suspend or withhold payment from the original Date of Payment, suspension, withhold or denial. (Attachment G-1.q) 32. Material Changes to Provider Manual, Reimbursement Policies or Clinical Policies. WellCare shall notify Participating Provider of updates to WellCare’s clinical policies electronically no later than 30 calendar days prior to the effective date of the policy, or at a date defined by the NC DHHS, directed to Participating Provider’s contact for notices under this Agreement via WellCare’s provider portal. Participating Provider may request written notification, at no additional cost, to be mailed no later than 30 days prior to the effective date of the policy, or at a date defined by the NC DHHS, of the policy. WellCare shall not implement any material changes to the clinical policies without express approval from the NC DHHS. (Section VII, Attachment G(3)(i)) 33. Contract Amendments with Individual Providers. For the purposes of this Section 33 only, the following terms shall have the following definitions: (i) “Amendment” shall mean any change to the terms of this Medicaid Product Attachment, including terms incorporated by reference, that modifies fee schedules. A change required by federal or State law, rule, regulation, administrative hearing, or court order is not an Amendment. (ii) “Contract” shall mean this Agreement, which is an agreement between WellCare and Provider for the provision of health care services by the provider on a preferred or in-network basis. (iii) “Health Benefit Plan” shall mean a policy, certificate, contract, or plan as defined in N.C. Gen. Stat. §58-3-167. (iv) “Health Care Provider” shall mean Provider if Provider is an individual who is licensed, certified, or otherwise authorized under Chapter 90 or Chapter 90B of the General Statutes or under the laws of another state to provide health care services in the ordinary course of business or practice of a profession or in an approved education or training program and a facility that is licensed under Chapter 131E or Chapter 122C of the General Statutes or is owned or operated by the State of North Carolina in which health care services are provided to patients. (v) “Insurer” shall mean WellCare (as otherwise defined herein), which is an entity as defined in N.C. Gen. Stat. §58-3-227(a)(4). Insurer shall send any proposed Contract Amendment to the notice contact of Health Care Provider pursuant to N.C. Gen. Stat. §58-50-275. The proposed Amendment shall be dated, labeled “Amendment,” signed by the Insurer, and DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210