2025 Transparency Notice

A) Non-network liability and balance billing

If you receive services from a non-network provider, you may have to pay more for services you receive. Non-network providers may be permitted to bill you for the difference between what we agreed to pay and the full billed amount for a service. This is known as balance billing. This amount is likely more than network costs for the same service and might not count toward your annual maximum out-of-pocket amount limit. However, you will not be balance billed when balance billing protections apply to covered services.

As a member of WellCare, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost sharing responsibilities when:

You receive a covered emergency service or air ambulance service from a non-network provider. This includes services you may get after you are in stable condition unless the non-network provider obtains your written consent.
You receive non-emergency ancillary services (emergency medicine, anesthesiology, pathology, radiology, and neonatology, as well as diagnostic services (including radiology and laboratory services)) from a non-network provider at a network hospital or network ambulatory surgical facility.
You receive other non-emergency services from a non-network provider at a network hospital or network ambulatory surgical facility unless the non-network provider obtains your written consent. Please refer to your Schedule of Benefits for an overview of your costs for out-of-network services.

B) Enrollee Claim Submission

Providers will typically submit claims on your behalf, but sometimes you may need to submit claims yourself for covered services. This may happen if your provider is not contracted with us.

If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid. We can adjust your deductible, copayment, or cost sharing to reimburse you.

To request reimbursement for a covered service, you need a copy of the detailed claim from your physician. You will also need to submit a copy of the member reimbursement claim form (PDF) posted at marketplace.wellcarenc.com under “Member Resources.” Send all the documentation to us at the following address:

WellCare of North Carolina
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

We must receive written proof of loss within 180 calendar days of the loss or as soon as is reasonably possible. Proof of loss furnished more than one year late will not be accepted, unless you or your covered dependent member had no legal capacity to submit such proof during that year.

After getting your claim, we will let you know we have received it, begin an investigation and request all items necessary to resolve the claim. We will do this in 30 days or less.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 30 business days as well. If we are unable to come to a decision about your claim within 30 business days, we will let you know and explain why we need additional time.

We will accept or reject your claim no later than 30 days after we receive it. If we reject your claim, the notice will state the reason why. If we agree to pay all or part of your claim, we will pay it no later than the 29 business days after the notice has been made.

C) Grace Periods and Claims Pending

If you don’t pay your premium by its due date, you’ll enter a grace period. This is the extra time we give you to pay.

During your grace period, you will still have coverage. However, if you don’t pay before a grace period ends, you run the risk of losing your coverage. During a grace period, we may hold — or pend — your claim payment.

If your coverage is terminated for not paying your premium, you won’t be eligible to enroll with us again until Open Enrollment or a Special Enrollment period.

When a member is receiving a premium subsidy:

After the first premium is paid, a grace period of 3 months from the premium due date is given for the payment of premium. Coverage will remain in force during the grace period. If full payment of premium is not received within the grace period, coverage will be terminated as of the last day of the first month during the grace period if advance premium tax credits are received.

We will continue to pay all appropriate claims for covered services rendered to the member during the first month of the grace period and may pend claims for covered services rendered to the member in the second and third month of the grace period. We will notify HHS of the non-payment of premiums, the member, as well as providers of the possibility of denied claims when the member is in the second and third month of the grace period. We will continue to collect advance premium tax credits on behalf of the member from the Department of the Treasury and will return the advance premium tax credits on behalf of the member for the second and third month of the grace period if the member exhausts their grace period as described above. A member is not eligible to re-enroll once terminated, unless a member has a special enrollment circumstance, such as a marriage or birth in the family or during annual open enrollment periods.

When a member is not receiving a premium subsidy:

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 60-day grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the policy will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member, as well as providers, of the possibility of denied claims when the member is in the grace period.

D) Retroactive Denials

"Retroactive denial of a previously paid claim" or "retroactive denial of payment" means any attempt by a carrier retroactively to collect payments already made to a provider with respect to a claim by reducing other payments currently owed to the provider, by withholding or setting off against future payments, or in any other manner reducing or affecting the future claim payments to the provider.

There are instances where claims may be denied retroactively if you: receive services from a provider or facility that is not in our network, terminate coverage with WellCare, provide late notification of other coverage due to new coverage, or have a change in circumstance, such as divorce or marriage. This causes WellCare to request recoupment of payment from the Provider.

If you believe the denial is in error, you are encouraged to contact Member Services Department by calling the number on your member identification card.

You can avoid retroactive denials by paying your premiums on time and in full, and making sure you talk to your provider about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider.

E) Recoupment of Overpayments

If you believe you have paid too much for your premium and should receive a refund, please contact Member Services immediately at the number listed on the back of your member identification card. Refunds are processed by two methods, electronically or by a manual check. The type of refund that is issued is dependent on the method of payment. Payments made with a debit/credit card via eCashiering, interactive voice response (IVR), auto pay, or member portal, as well as credit card payments sent to our lockbox vendor, will be refunded via eCashering. Payments made via eCheck will also be refunded electronically. Payments made by check to our lockbox vendor and payments that were processed in-house at our Little Rock location must be refunded manually via live check.

F) Medical Necessity and Prior Authorization

Services are only covered if they are medically necessary. Medically necessary means those covered services, items, or supplies that are:

Provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease; and except as allowed for clinical trials under G.S. 58-3-255, not for experimental, investigational, or cosmetic purposes;
Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms;
Within generally accepted standards of medical care in the community; and
Not solely for the convenience of the member, the member’s family, or the provider.

Charges incurred for treatment not medically necessary are not eligible service expenses.

Prior Authorization Required

Some covered service expenses (medical and behavioral health) require prior authorization, as more fully detailed in the Schedule of Benefits. In general, for services that require prior authorization, network providers must obtain authorization from us prior to providing a service or supply to a member. However, there are some network eligible expenses for which you must obtain the prior authorization.

For services, items, or supplies that require prior authorization, as shown on the Schedule of Benefits, you must obtain authorization from us before you or your dependent member:

Receive a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Receive a service or supply from a network provider to which you or your dependent member were referred to by a non-network provider.

The following services or supplies require prior authorization:

Non-emergency health care services provided by non-network providers;
Reconstructive procedures;
Diagnostic tests such as specialized labs, procedures and high technology imaging;
Injectable drugs and medications;
Inpatient health care services;
Specific surgical procedures;
Nutritional supplements;
Pain management services; and
Transplant services.

Prior authorization requests (medical and behavioral health) must be received by phone/efax/physician portal as follows:

At least 5 calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice facility, or residential treatment facility.
At least 30 calendar days prior to the initial evaluation for organ transplant services.
At least 30 calendar days prior to receiving clinical trial services.
Within 24 hours of any inpatient admission, including emergent inpatient admissions.
At least five calendar days prior to the start of home health care, except those members needing home health care after hospital discharge.

After prior authorization has been received, we will notify you and your physician if the requet has been approved as follows:

For urgent concurrent review within one calendar day of receipt of the request.
For urgent pre-service reviews, within three calendar days from date of receipt of request.
For non-urgent pre-service reviews within three business days of receipt of all necessary clinical information.
For post-service or retrospective reviews, within 30 calendar days of receipt of the request.

In situations where additional information is needed to make a decision, these timeframes may be extended in accordance with applicable law.

You do not need to obtain prior authorization from us or from any other person (including your PCP) in order to obtain access to obstetrical or gynecological care from a medical practitioner in our network who specializes in obstetrics or gynecology. The medical practitioner, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating medical practitioners who specialize in obstetrics or gynecology, contact Member Services.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced.

Network providers cannot bill you for services for which they fail to obtain prior authorization as required.

Benefits will not be reduced for failure to comply with prior authorization requirements prior to receiving emergency services. However, you must contact us as soon as reasonably possible after you receive the emergency services.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription Drug Exception Process

Sometimes members need access to drugs that are not listed on the formulary. Members or provider can submit a drug exception request to us by contacting Member Services or by sending a written request to the following address:

WellCare of North Carolia
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

Standard exception request

A member, a member’s authorized representative or a member’s prescribing physician may request a standard review of a decision that a drug is not covered by the plan or a protocol exception for step therapy. The request can be made in writing or via telephone. Within 72 hours of the request being received, we will provide the member, the member’s authorized representative or the member’s prescribing physician with our coverage determination. Should the standard exception request or step therapy protocol exception request be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills, or of the drug that is the subject of the protocol exception.

Expedited exception request

A member, a member’s authorized representative or a member’s prescribing physician may request an expedited review based on exigent circumstances. Exigent circumstances exist when a member is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug. The request can be made in writing or via telephone. Within 24 hours of the request being received, we will provide the member, the member’s authorized representative or the member’s prescribing physician with our coverage determination. Should the standard exception or step therapy protocol exception request be granted, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception for the duration of the exigency.

External exception request review

If we deny a request for a standard exception or for an expedited exception, the member, the member’s authorized representative or the member’s prescribing physician may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization. We will make our determination on the external exception request and notify the member, the member’s authorized representative or the member’s prescribing physician of our coverage determination no later than 72 hours following receipt of the request, if the original request was a standard exception, and no later than 24 hours following its receipt of the request, if the original request was an expedited exception.

If we grant an external exception review of a standard exception or step therapy protocol exception request, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception for the duration of the prescription. If we grant an external exception review of an expedited exception request, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception for the duration of the exigency.

H) Information on Explanations of Benefits

An Explanation of Benefits (EOB) is a statement that we send to members to explain what medical treatments and/or services we paid for on behalf of a member. This shows the amount billed by the provider, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy. We will send an EOB to a member after we receive and adjudicate a claim on your behalf from a provider. If you need assistance interpreting your Explanation of Benefits, please contact Member Services.

I) Coordination of Benefits

Due to North Carolina Law, WellCare does not coordinate benefits with other commercial plans.

However, coordination with Medicare may be required to avoid duplication of benefits when WellCare members who become eligible for and enroll in Medicare.

This provision describes how we coordinate and pay benefits when a member is also enrolled in Medicare and duplication of coverage occurs. If a member is not enrolled in Medicare or receiving benefits, there is no duplication of coverage and we do not have to coordinate with Medicare.

The benefits under the policy are not intended to duplicate any benefits to which members are entitled under Medicare.

Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status, and will be adjudicated by us as set forth in this section. In cases where Medicare or another government program has primary responsibility, Medicare benefits will be taken into account for any member who is enrolled for Medicare. This will be done before the benefits under this health plan are calculated. When Medicare, Part A and Part B or Part C is primary, Medicare's allowable amount is the highest allowable expense.

When a person is eligible for Medicare benefits and Medicare is deemed to be the primary payer under Medicare secondary payer guidelines and regulations, we will reduce our payment by the Medicare primary payment and pay as secondary up to the Medicare allowable amount. However, under no circumstances will this plan pay more than it would have paid if it had been the primary plan.

Charges for services used to satisfy a member’s Medicare Part B deductible will be applied in the order received by us. Two or more expenses for services received at the same time will be applied starting with the largest first.

This provision will apply to the maximum extent permitted by federal or state law. We will not reduce the benefits due any member because of a member's eligibility for Medicare where federal law requires that we determine its benefits for that member without regard to the benefits available under Medicare.

Members may no longer be eligible to receive a premium subsidy for the Health Insurance Marketplace plan once Medicare coverage becomes effective.