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North Carolina Medicaid Good Faith Contracting Policy

May 19, 2021

WellCare NC Medicaid Good Faith Contracting Policy

1. The network will be developed, filed, and maintained to meet the Department’s availability, accessibility, and quality goals and requirements in accordance with state regulations, accrediting bodies, and company guidelines.

2. During the initial development of the network, WellCare will proactively reach out to providers with an offer to contract in writing. WellCare will use the Department’s historical claims payment file to send contracts to all providers actively seeking Medicaid eligibility, as well as all hospital systems, AMH certified providers, essential providers, key provider groups and all other required provider types. Follow up activities after written offers are made will take place within 10 business days, either by phone or email to ascertain interest and answer questions. All offers and follow up activities will be documented in WellCare’s contract management system and will include date of initial offer and any follow up performed by phone or email.

3. If WellCare receives a direct inquiry for a contract, either in writing or via telephone,WellCare will engage in contract negotiations by offering the provider a contract. WellCare will negotiate, regardless of provider or PHP affiliation, to contract with providers in writing and all offers shall include the required standard provisions as required by the state of North Carolina.

4. If within thirty (30) calendar days the potential network provider rejects the request or fails to respond either verbally or in writing, WellCare may consider the request for inclusion in the Medicaid Managed Care Provider Network rejected by the provider. If discussions are ongoing, or the contract is under legal review, WellCare shall not consider the request rejected. The 30 day period begins when the provider has received a copy of the contract that is consistent with the version of the contract approved by the department.

5. WellCare shall not include any provider in its network that is not currently enrolled in North Carolina Medicaid consistent with provider, disclosure, screening and enrollment requirements of 42 CFR Part 455 Subpart B and E.

6. WellCare shall not require individual practitioners, as a condition of contracting with WellCare, to agree to participate or accept other products offered by the WellCare, nor shall WellCare automatically enroll the provider in any other product offered by WellCare. This requirement shall not apply to facility providers.

7. WellCare, or any sub-contractor delegated responsibility by WellCare for coverage of services and payment of claims under the Contract, shall not include exclusivity or non- compete provisions in contracts with providers, including non-medical service providers (e.g. non- emergency medical transportation drivers). WellCare will not require a provider to participate in the governance of a PLE, or otherwise prohibit a provider from providing services for or contracting with any other PHP.

8. WellCare shall not exclude eligible providers from its network except under the following circumstances:

  1. Provider fails to meet or maintain Objective Quality Standards as outlined in Credentialing/ Re-credentialing Policy (NC35-CR-001)
  2. When a provider refuses to accept network rates, which shall not be lower than the applicable rate floor unless mutually agreed to an alternative reimbursement or methodology.

9. If a provider accepts the terms and conditions of the WellCare Participating Provider Agreement and accepts network rates, all final decisions to contract with a provider flow from the Participation Committee decision following quality determinations

10. WellCare shall give written notice to any provider with whom it declines to contract with and provide a process to cure the issue identified in the Quality Determination. Upon cure, the parties may initiate a new good faith contracting effort:

  1. When the Provider Network Participation Committee determination is adverse to the applicant and/or renewal applicant, the State Medical Director or designee in a timely manner informs the applicant within 5 days by special notice that he/she is entitled to appeal the decision.
  2. Appeals will be accepted within thirty (30) calendar days from receipt of notice of the decision. Appeal time frame may be extended by an additional thirty (30) calendar days for good cause.
  3. WellCare must acknowledge receipt of an appeal request within five (5) calendar days

11.If WellCare requires a provider to submit additional information as part of its contracting process, the request shall include a description of all such information required for contracting, claims payments and directory display in accordance with the regulatory agencies, accrediting bodies, and WellCare of North Carolina requirements.

12.WellCare shall track all good faith contracting efforts in order to document all facts and circumstances surrounding a provider’s willingness to contract and/or refuse.

13. WellCare shall consider all facts and circumstances surrounding a provider’s willingness to contract before determining that the provider has refused the plan’s “good faith” contracting effort.

14. With the exception of out of network emergency services, post-stabilization services and services provided during transitions in coverage, WellCare shall be prohibited from reimbursing an out of network provider more than ninety percent (90%) of the Medicaid Fee-for-Service rate if:

  1. WellCare has made a good faith effort to contract with a provider but the provider has refused that contract, or
  2. The provider was excluded from the PHP’s network for failure to meet Objective Quality Standards.

Additional Language:

All Policies and Procedures (“Documents”) are required to be reviewed at least biennially, unless required more frequently by state regulation or contractual obligation. The review includes collaboration with Stakeholders and may also require regulatory or state approvals. Upon completion of the review, the Documents must be approved and published in C360 to be valid. To facilitate this timing, reviews should commence 90 days prior to one calendar year from the current New, Reviewed or Revised date.

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Last Updated On: 5/19/2021