| Topic | Description |
|---|---|
| Provider Registration Process | Learn how to register for a WellSense HealthTrio account. |
| Portal Overview and Basic Functionality | Gain an understanding of the portal's basic functionality, including checking member eligibility and looking up diagnosis codes |
| Claim Submission | Learn the steps for submitting a claim through the portal. |
| Update Claims | Learn how to use the Request for Claim Review Form for all EDI claim corrections and claim re-adjudication requests. |
| Office Management | Learn how to revalidate account users and add, remove or modify users. |
| Prior Authorizations | Use this training aid to submit prior authorizations online. |
| Manage Member Information | Learn how to update various member data online. |
Provider Portal Registration Tutorial
Learn how to register for a WellSense provider account in our new HealthTrio portal.
Provider Portal Eligibility Tutorial
Learn how to check member eligibility in our provider portal.
Provider Portal Claims Tutorial
Learn how to view the status of a claim, search for a remittance advice, and submit claims manually.
Provider Portal Prior Authorization Tutorial
Learn how to submit prior authorization requests and check the status of your requests.
All contracted providers have a dedicated Provider Relations Consultant to help them and their associates (ancillary providers, clinicians, vendors, administrative staffs, hospital staffs, and health center staffs) navigate our system, and understand our policies and procedures. Your Provider Relations Consultant will:
- Respond promptly to your questions and concerns
- Provide ongoing education and support
- Serve as your point of contact with WellSense
- Create reports at your request (for example, inpatient census reports, member panel reports, emergency department utilization reports, and ad hoc data requests)
- Help you determine which services are covered and/or require prior authorization
- Work with you to correct claims
Questions? Need Training or Support from WellSense?
- Call your Provider Relations Consultant
- Call our provider line at 888-566-0008
- Send an email to provider.Info2@wellsense.org
Please note:
- Behavioral health providers should call Carelon Behavioral Health at 866-444-5155 for any questions or issues that they may have.
- Durable medical equipment, prosthetic, orthotic and medical supply (DMEPOS) providers should contact Northwood, Inc. at 866-802-6471 for any questions or issues that they may have.
- Radiology providers (not including those associated with observation or ER visits) should contact eviCore at 866-802-6471 with questions or concerns.
The Healthcare Effectiveness Data and Information Set (HEDIS®) is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service.
What are HEDIS scores used for?
HEDIS rates are used to evaluate a health insurance company’s ability to engage its members in preventive health care practices. Physician-specific scores are used to evaluate practices’ ability to provide a wide array of care to their patients ranging from health screenings to medication management. These rates guide health plans and physicians in targeting quality improvement activities where they will have the greatest impact on member and patient health care outcomes. BMC HealthNet Plan uses HEDIS rates to ensure our members are offered the highest possible level of health care. To aid in documenting, coding, and billing HEDIS activities appropriately, we’ve developed a HEDIS Billing & Coding Guide for providers. Please note: This resource is not all-inclusive, and is not intended to replace professional coding standards.
How are the rates measured?
HEDIS rates are measured by using either administrative or hybrid data. Administrative measures are calculated based on claims or encounter data submitted to the health plan. Hybrid measures are calculated using administrative data plus a sample of medical record data. A random sample of member medical records are reviewed to abstract data for services that were rendered, but were not reported through claims or encounter data. Accurate and timely submission of administrative data reduces the necessity of medical record review.
How can I improve my HEDIS scores?
- Submit accurate claim/encounter data for each and every service rendered
- Ensure medical record documentation reflects all services billed
- Bill (or report by encounter submission) for all services delivered, regardless of contract status
- Consider including CPT II codes to reduce medical record requests
- Continue to submit claim/encounter data on a timely basis
For more information about calculating or improving HEDIS scores, please contact Karen Szvoren, RN, Clinical Initiatives Manager via email or by phone at 617-748-6111.
Learn more about the MassHealth Community Partners (Behavioral Health & Long Term Services and Supports) program.
Enhancing your communication skills helps you to provide quality care to all your patients regardless of race, ethnicity, or religious beliefs. The resources below can help you assess and improve your cultural competency.
Cultural Competency Training - A free, online educational program accredited for physicians, physician assistants, and nurse practitioners. A training program is also available for nurses and social workers.
New National CLAS Standards - An implementation guide from The Office of Minority Health to help you advance health equity and quality for all cultures within your healthcare organization.
MassHealth and the Massachusetts Health Connector require that providers follow the guidelines below when discussing health plan options with individuals eligible for MassHealth.
- Please do not make unsolicited contact with MassHealth or CarePlus patients to influence them to enroll in a Managed Care Organization.
- You may answer questions about our MassHealth and CarePlus products if patients ask about them. You may also refer them to call 800-792-4355.
- You may put approved WellSense and CarePlus brochures and posters in your facility.
- If a MassHealth or CarePlus patient wants to join WellSense, refer him/her to the MassHealth service line at 1-800-841-2900. The patient may use your phone, but do not make the call for him/her.
- You may help patients with their MassHealth or CarePlus eligibility and applications.
- In the course of treating a patient, you may talk to him or her about benefits or services available from any of the Managed Care Organizations if the benefit or service relates to the patient's treatment needs.
- You may talk with MassHealth or CarePlus members about anything to do with their plan membership, including extra items and services, choosing a primary care provider, how to get a new ID card, or other member questions.
Approvals
- Marketing materials developed by WellSense or its providers regarding the MassHealth program require MassHealth approval.
- Marketing materials developed by the Plan or its providers regarding CarePlus, ConnectorCare, or Qualified Health Plans require Health Connector Approval.
- WellSense will obtain MassHealth and/or the Health Connector's approval. Please contact your Provider Relations representative if you have any questions or require assistance.
For specific information on marketing guidelines and what defines marketing, please consult the Provider Manual, section 6.
A general overview of the WellSene ACO Program and some of the changes that will be taking place as a result of Medicaid ACO Reform changes that become effective March 1, 2018.
Frequently Asked Questions
Answers to frequently asked questions about accountable care organizations (ACOs).
Our Senior Care Options (SCO) Model of Care requires that network providers receive WellSense-specific Model of Care training. This training will be provided annually and to newly-participating providers. For your convenience, we have developed a short, web-based training module regarding our Model of Care:
- At the end of the training you will be asked to click thorough to attest that you have completed the training. To complete the attestation you must have your NPI number.
- We hope you find this training informative. If you have additional questions, please contact your dedicated Provider Relations Consultant.