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Appeals and Inquiries

 

Two Levels of Review
Inquiries
Postservice Provider Appeals
Frequently Asked Questions 

 

Two Levels of Review

Learn about the two sequential levels of review for disputed claims:

 

Step Review Level Method of Submission Review Process/Timeframe

1

Inquiry

Via one of these methods:

  • Web Provider Service inquiry
  • Provider Inquiry Form
  • Provider Service phone call

Inquiry must be submitted within 18 months of the date of the provider's remittance on which the original claim in question appeared.

2

Appeal

Provider PostService Appeal Form only

Claim examined by staff not involved in initial decision or review. Appeal must be received by Wellmark within 180 days from the date of the Provider remittance on which the claim in question appears.

 

Inquiries

If you are not satisfied with a claim adjudication, submit a provider inquiry and any accompanying information Wellmark should consider:

  • Online - Ask a Question  of Customer/Provider Service and track the progress of the inquiry online.
  • By phone - Call the appropriate Customer/Provider Service phone number for Iowa or South Dakota.
  • By fax or mail - Complete and submit the Iowa  or South Dakota  Provider Inquiry Form.

If the inquiry is not resolved to your satisfaction and new information is available, please submit a second inquiry with the additional information.

 

If no additional information is available, you may submit a postservice provider appeal.

Post-Service Provider Appeals

If you are not satisfied with Wellmark's determination after exhausting the process above, you may submit an appeal to Wellmark's provider appeals department using the Iowa  or South Dakota  Provider Post-Service Appeal Form.

 

Please include any written comments, office notes, operative reports, or other relevant information for Wellmark to consider during the appeal. Wellmark will return incomplete forms to you.

 

You have 180 calendar days from the date of the remittance advice to dispute a claim adjudication action.

 

You may not initiate an appeal if:

  • The plan member or plan member's authorized representative has already filed a preservice appeal or a postservice review pertaining to the same service.
  • The member has filed a lawsuit.

Wellmark will send you a letter dismissing the appeal if any of the above conditions exist. 

 

The appeal review will take into account all documents, medical records, or any additional information, regardless of whether the information was submitted or considered in the original determination or provider inquiry.

 

Appeals will be conducted by individuals not involved in the previous determination. Based on the type of issue being appealed, the following may conduct the review:

  • Wellmark's provider economics department
  • Medical directors
  • Medical review department
  • Medical policy group
  • Provider contracting departments
  • Other business areas as needed
  • A physician with the same or similar specialty or who has experience treating the same problems as those in question on the appeal (for medical necessity appeals)

Wellmark will notify you of the appeal decision within 30 calendar days of receipt of the appeal.

 

Note: The provider appeal process is available for postservice reviews only. Members may appeal preservice utilization review decisions in accordance with the member appeals process. If a provider would like to request a preservice appeal on behalf of the member, the provider will need to follow the member appeal process and be appointed by the member as an authorized representative using an Iowa  or South Dakota  Authorized Representative Appointment Form.

Frequently Asked Questions

How do I know if I've exhausted the provider inquiry process?
If your initial provider inquiry is not resolved to your satisfaction, and new information is available, you may submit a second inquiry with the additional information. If no additional pertinent information is available, you have exhausted the provider inquiry process and may submit a formal provider appeal for a subsequent review.

 

I had a claim reviewed earlier this year. Can I submit an appeal now?
If your initial provider inquiry is not resolved to your satisfaction, you may submit an appeal, as long as the request is received by Wellmark within 180 days of the remittance date of the claim in question.

 

What is the benefit of filing an appeal?
An appeal is examined by staff members who were not involved with the initial decision or review.

 

How will I know the results of the appeal?
Following the review, you will receive a written response in the mail, regardless of the outcome. Wellmark's response will be mailed within 30 calendar days of our receiving your request.

 

What review options exist after the appeal if there is no additional information?
The appeal is the final option. If there is no additional information to submit, Wellmark is finished reviewing the claim.



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