WellCare-Centene Fixes OCT Claims Problem, But New Imaging Claims Denials Surface

The insurer WellCare-Centene has agreed to perform retroactive corrections for erroneous optical coherence tomography (OCT) claims denials that the Academy raised in January.

The insurer said in a meeting with the Academy on Monday that it will automatically reprocess the claims, although it will take some time. Members who were incorrectly denied payment in 2020 for treating patients with diabetic retinopathy and age-related macular degeneration can now expect to receive reimbursements.

In January, the Academy brought the issue to WellCare-Centene’s attention. The company assured us that the policy causing the denial had been corrected in November and agreed to explore retroactive payment.

New Claim Denials

In addition to discussing the OCT claims issue with the insurer this week, the Academy told WellCare-Centene that some members recently reported they were being denied claims for fluorescein angiography (92235) and fundus photography (92250). Members provided the Academy with those denials, which noted that “benefit maximum has been reached.”

WellCare-Centene told us that these denials were sent to its claims department to be corrected, as they should not have been denied. The cause for the denial is unclear, but the insurer said its claims department is researching the matter.

If you received a claim denial for OCT that has not been reprocessed by mid-March, let us know so we can communicate that with WellCare-Centene. Also, continue to notify us of denials for all retina testing with an explanation noting that maximum benefits were reached. Contact the Academy’s coding department at coding@aao.org.

We will continue to update you on developments related to this issue.