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Wellmark's Claims Appeal and External Review Process

Finding out that a claim has been denied or paid differently than you expected can be frustrating.  It’s important you understand the reasons behind any decision to deny payment for a claim (also known as an adverse benefit determination). You can always contact Customer Service with a question about how a claim was decided, but for a full and fair review of a denied claim, use Wellmark’s Claims Appeal and External Review Process.

 

Here’s How It Works

 

Step I:  Filing an Appeal for Review by Wellmark

  • Whether you have coverage through your employer or you are an individual policyholder, you have a right to file an appeal when you receive an adverse benefit determination for payment of services under your benefit plan. (If your employer has a “self-funded” group health plan, the group is responsible for final claim determinations. However, your employer may have Wellmark review appeal requests on behalf of the self-funded plan.)
  • Individuals applying for individual insurance policies may also file an appeal if their application for membership is initially denied through the medical underwriting process.
  • The appeal must be filed in writing using a Wellmark Appeal/Review Form for Iowa  or South Dakota  and must be filed within 180 days of the date of the decision. However, if the situation is medically urgent, the appeal may be submitted verbally by calling Wellmark.
  • More information is available in our How to Appeal notifications for Iowa  and South Dakota .

Step 2: Filing a Request for External Review

 

If you have exhausted our internal Appeal Process (Step 1) and you are not satisfied with the outcome (final adverse benefit determination) relating to a covered benefit that is denied, and the claim denial involves medical judgment or appropriateness, you may request an external review with the state’s insurance division:

  • The request must be filed in writing using an External Review Request Form for Iowa  or South Dakota . External review may not be available for all members or for all types of claims, and is not available for Medicare Supplemental or most dental plans. Self-funded group health plans may use a different external review process.
  • An expedited external review process is available if you have a medical condition where a delay in treatment could seriously jeopardize your life or health, or the ability to regain maximum function. Information regarding an expedited external review may be available from the state insurance division.

Please refer to your health plan benefits document, coverage manual or summary plan description for additional details on the Internal Appeal and External Review Processes that is applicable to your specific plan.

 



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