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Posts about Provider Alerts:

Pilot: Riverside and San Bernardino Networks | Improved WelbeHealth Referral Forms

Cristal Gonzalez
Provider Alerts

From: WelbeHealth
To: Health Plan Providers
Type: Informational
Subject: Improved WelbeHealth Referral Forms
Business: PACE
State(s): PACE – California

Pilot: Riverside and San Bernardino Networks | Improved WelbeHealth Referral Forms – Designed with Your Feedback

WE HEARD YOU

Dear WelbeHealth Contracted Providers,

As we approach the close of 2025, the WelbeHealth team is pleased to share updates to our Referral Forms, designed to make your experience smoother and more efficient.

Based on your feedback, we have refined the forms to improve navigation and visibility of key information, helping you quickly identify what you need and streamline the referral process.

These enhancements reflect valuable insights from our contracted providers. Our goal is to create a more user-friendly experience and better support your success in partnering with WelbeHealth.

We welcome your continued feedback to help us strengthen the way we work together. If you have questions or suggestions regarding the updated referral forms, please reach out to your Provider Partnership Associate directly or contact us at providers@welbehealth.com.

Thank you for your ongoing commitment to delivering exceptional care to our Participants. We truly appreciate all that you and your team do every day.

Thank you for being a valued partner.

Warm regards,

The WelbeHealth Team

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If you have any questions, please contact your Provider Partnership Representative, or email the Provider Partnership team at providers@welbehealth.com. You may also visit welbehealth.com/partners for online access to this document and all other WelbeHealth Provider Alerts

Claims Timely Payments

Cristal Gonzalez
Provider Alerts

From: WelbeHealth
To: Health Plan Providers
Type: Informational
Subject: Change – Claims Processing
Business: PACE
State(s): PACE – California

Claims Timely Payments

Beginning January 1, 2026, the Department of Health Care Services (DHCS) will implement a new process for timely processing of claims. Assembly Bill 3275 states, upon receipt of a Complete Claim, payment or denial will be made within thirty (30) calendar days. WelbeHealth shall notify Providers in writing no later than thirty (30) calendar days after receipt of a claim. If a claim or a portion is contested (denied), the notice will identify the specific reason WelbeHealth is contesting (denying) the claim.

If an uncontested (paid) claim is not reimbursed by delivery to the provider’s address of record within 30 calendar days after receipt, interest accrues at 15% per annum, beginning with the first calendar day after the 30-calendar day period. If the interest payment is not included in the claim payment, WelbeHealth pays the provider an additional fifteen dollars ($15) or ten percent (10%) of the accrued interest on the claim.

The requirement for interest and penalty applies to all claims, including claims for emergency services and care.

Claim Timely Filing Limits

Effective January 1, 2026, corrected claims and correspondence claims submission time frames have changed to the following:

Clean Claims
The term listed in your agreement, or 365 days from the Date of Service

Corrected Claim
180 days from the Date of Service unless the original claim was denied, then 180 days from the Remittance Advice (RA)

Correspondence
180 days from the date of the Remittance Advice (RA)

Provider Dispute (PDR)
The term listed in your agreement or, 365 days from the date of action/inaction

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If you have any questions, please contact your Provider Partnership Representative, or email the Provider Partnership team at providers@welbehealth.com. You may also visit welbehealth.com/partners for online access to this document and all other WelbeHealth Provider Alerts

Important Network Updates & Enhancements

Cristal Gonzalez
Provider Alerts

From: WelbeHealth
To: Health Plan Providers
Type: Informational
Subject: Important Network Updates & Enhancements
Business: PACE
State(s): PACE – California

We are excited to share several important updates to support your work and streamline your interactions with WelbeHealth:

1. Reminder: Claims Submission Updates Effective 10/01/25
Action Required: Update your systems immediately to avoid delays.

  • We no longer accept paper claim submissions – Do not send claims/disputes/ correspondence to PO BOX 30760, Tampa, FL 33630-3760
  • Submit electronic claims (no attachments):
  • Claims with documentation should be faxed to (626) 209-4367
  • Provider Disputes & Correspondence should be faxed to (626) 498-2099 with proper forms and documentation for each.

2. New Claims Payment Schedule – Effective Week of Nov 3, 2025
To improve the timeliness of claims payments:

  • We will conduct two check runs per week: Tuesdays & Fridays
  • Schedule adjusted if a holiday falls on these days

3. New IVR System – Live 09/22/25
Our Interactive Voice Response (IVR) system reduces wait times and helps you:

  • Get authorization details
    Check claim status
    Verify participant eligibility
    Reduce hold times

Try our new IVR System by calling us at (650) 336-0300.

4. Provider Manual has been updated and is Live on our website!
Access the updated manual on our website: https://welbehealth.com/partners/

5. New Participant ID Cards
New cards were mailed to all participants.
Action Required: Request an updated ID card during visits and ensure your billing systems reflect the updated information for accurate claims submission and processing.

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If you have any questions, please contact your Provider Partnership Representative, or email the Provider Partnership team at providers@welbehealth.com. You may also visit welbehealth.com/partners for online access to this document and all other WelbeHealth Provider Alerts

Exciting News: More Flexibility for External Specialist Services!

Cristal Gonzalez
Provider Alerts

From: WelbeHealth
To: Health Plan Providers
Type: Informational
Subject: Effectuation of Care (EOC) – Specialist Flexibility
Business: PACE
State(s): PACE – California

Dear Valued Provider,
WelbeHealth is excited to share an update that makes working with us easier while ensuring timely access to care for our participants.

What’s Changing?
Specialists now have the clinical oversight to provide additional services during an existing appointment. These services may be performed or scheduled at the same or a follow-up visit if not on the Prior Authorization (PA) List.

Specialist Definition: A specialist is a licensed healthcare professional with advanced training in a specific area of medicine or behavioral health who provides evaluation, diagnosis, or treatment services outside the participant’s primary care setting.

Please Note – Exceptions:
• Laboratory Services (including blood draws, urine testing, pathology, etc.) – excluded from this process and must continue to follow existing workflows.
• Dental specialists – Managed separately under the Dental process.

Key Reminders
• Initial Orders: All services must start with a WelbeHealth order; specialists cannot initiate the first order.
• Prior Authorization:
o Services not on the PA List do not require PA when delivered during external specialist visits.
o Services on the PA List must follow our standard PA process:
•  PA List: welbehealth.com/partners
• Submit requests via QuickCap Provider Portal (preferred) or fax the Authorization Request Form to (209) 729-5854.

• Medical Records: Case notes must be submitted within five (5) days of the Date of Service.

Why This Matters?
• Less administrative burden
• Expanded access to services
• Stronger collaboration between providers and WelbeHealth

WelbeHealth Provider Partnership Department

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If you have any questions, please contact your Provider Partnership Representative, or email the Provider
Partnership team at providers@welbehealth.com . You may also visit welbehealth.com/partners. for online access to
this document and all other WelbeHealth Provider Alerts

Prior Authorization List

Cristal Gonzalez
Provider Alerts

From: WelbeHealth
To: Health Plan Providers
Type: Informational
Subject: Prior Authorization List
Business: PACE
State(s): PACE – California

Our Prior Authorization List has been updated to reflect changes that are effective October 1, 2025.

Codes Being Added

  • 15275 – High-cost wound care code
    Rationale: Added to ensure appropriate utilization of advanced wound care procedures.
  • 43239, 45380, 45385, 45388 – Colonoscopy codes
    Rationale: Added to promote accurate procedure review and improve alignment with clinical guidelines.
  • 99999 – Unlisted procedure code
    Rationale: Added to ensure unlisted services undergo prior review to determine clinical appropriateness.

Codes Being Removed

  • 99199 – Unlisted special service
    Rationale: This code does not require prior authorization under our current configuration and has been removed to align the PA list with system settings.
  • 45378 – Diagnostic colonoscopy
    Rationale: Due to broad approval criteria, this code will always be approved and does not require prior authorization.

For the most current version of the PA list, please visit https://welbehealth.com/partners/. Requests for prior authorization can be submitted via:
Our provider portal (for contracted providers): https://welbehealth.quickcap.net/ Or complete our Prior Auth Form and send via Fax: (209) 729-5854.

Thank you for your continued partnership in delivering high-quality care to our participants.

______________________________________________________________________________________________________________

If you have any questions, please contact your Provider Partnership Representative, or email the Provider Partnership team at providers@welbehealth.com. You may also visit welbehealth.com/partners. for online access to this document and all other WelbeHealth Provider Alerts