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Home Health & Skilled Nursing Facility – New Audit Program

12/29/2025

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 08/01/26.

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, Wellcare 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 Frequently Asked Questions with useful information in communication.

Sincerely,
Wellcare

 

Mga Madalas Itanong

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Y0020_WCM_178064E_M Last Updated On: 11/10/2025