Electronic Claim Transaction Registration/Enrollment Forms
Member Related Forms and Questionnaires
- Member Coordination of Benefits Questionnaire
- Workers' Compensation Questionnaire
- Authorization to Use or Disclose Protected Health Information
Personal Representative Appointment
Network Participation Forms
All forms regarding network participation are available at our Credentialing and Contracting page. On our page, you will also find the Credentialing Submission Tracker where you are able to track the status of your applications, recredentialing submissions, and change requests.
Paper Claim Forms
Pharmacy exception requests for non-formulary medications
A non-formulary drug is a drug that is not covered under a prescription drug plan because cost-effective alternatives are available under the formulary drug coverage.
When one of your members needs a drug that is not on their formulary drug list, complete an initial Exception Request for Non-formulary Prescription Drug and fax it to the number on the form. The form is interactive and can be completed online and then printed and faxed.
Note: This form is different than a prior authorization request, which allows Wellmark to verify a prescription drug is part of a specific treatment plan and is medically necessary.
A complete form with necessary documentation is required so the request can be reviewed and a decision can be made. The information submitted for the request must provide a medical justification supporting the need for the non-formulary drug. The justification must show one of the following:
- All formulary drugs on any tier will be or have been ineffective.
- All formulary drugs on any tier would not be as effective as the non-formulary drug.
- All formulary drugs would have adverse effects.
If the initial formulary exception request is denied and you do not agree with our decision, the member may request an independent review of the formulary exception. Details regarding the process for independent review of an exception request will be provided in the denial notification letter for the initial request. Note: Should the member choose to request an independent review and the decision is made to uphold the denial, the decision is final and no other steps can be taken for coverage of the requested drug as a benefit of the member’s plan. It will not be eligible for appeal.
Prior Authorization Process
Providers should fill out Wellmark's universal request form for drugs that require prior authorization. Please start by referring to the Pharmacy Prior Authorization page. There you will find an alphabetical listing of medications with Wellmark's corresponding pharmacy policy. If a medication is not listed, Wellmark does not maintain a pharmacy policy for it.
To request prior authorization for Synagis (palivizumab), please fill out the Synagis enrollment form .
To enroll your patients in specialty pharmacy programs, please use the Caremark Specialty Pharmacy enrollment form or the Hy-Vee Pharmacy Solutions (HPS) enrollment form .
Physical Medicine Form
Prior Approval Medical Forms
- Prior Approval Form (To determine when to complete this form, visit Important Authorization Terms. These forms are only to be used for non-contracting or out-of-state providers. Contracting providers need to use the online Utilization Management Tool.)
Provider Claim Review Forms
For guidance, please visit the Appeals and Inquiries page.
Note: The post-service provider appeal process does not apply to overpayment recovery requests. If you have received an overpayment recovery request and do not agree with our reasons for requesting the refund, submit an overpayment recovery appeal.
To submit out of network and referral requests, use the online Utilization management tool. Please refer to the Quick Start Guide .
Skilled Nursing Provider Forms