04/30/26
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 6/1/2026.
| Description of Changes | Lines of Business |
|---|---|
| Home Health & Skilled Nursing Facility – New Audit Program: This program is a comprehensive medical record audit to validate the services billed and reimbursed are accurately documented in the provider’s medical records in accordance to policy CC.PI.11 – Payment Integrity Vendor Post Payment Audits (Home Health, SNF and DME). Centene Payment Integrity will implement a post-payment audit for a select sample of network claims each month. To support this process, Ambetter from Louisiana Healthcare Connections will use an approved vendor, Performant, to complete these audits. Providers who have a claim selected for post-payment audit will receive written notice of the audit and be asked to supply medical record documentation to Performant to substantiate the services associated with the claim. |
Medicare |
Denial Codes in Xcelys:
- RV116 - Payment Reversal-requested info not provided or insufficient
- RV117 - Payment Reversal-Incorrect Submission/Provider Billing Error
- RV213 - Technical denial due to medical records not received
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. For additional support, see FAQs below with useful information in communication.
Sincerely,
Wellcare
Mga Madalas Itanong
Why is this claim being audited?
Performant conducts DME, Home Health, and Skilled Nursing Facility audits. This clinical validation reviews medical documentation to ensure each diagnosis, procedure, or supply is documented and supported by clinical record.
What do I do if I have questions regarding an audit?
Please contact Performant Customer Service Department at the number below.
1-844-308-3781
Monday-Friday
9am to 5pm EST
Where do I send medical records when requested for an audit?
Mail: Performant Healthcare Solutions, Inc.
ATTN: Records Department
PO Box 3568
San Angelo, TX 76902
Fax: 1 (925) 245-8244
Online: Using the NaviNet portal as described above.
Which reason codes indicate a Performant audit?
Reason codes RV116, RV117, & RV213 found on the Explanation of Payment (EOP) will indicate that a claim was recouped/adjusted due to a Performant audit.
