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Forms

Below are the current versions of most common provider forms. Please check forms in your office to ensure your versions are the most up-to-date. To order a large supply of forms or to order materials not listed on this page, use the Iowa pdf or South Dakota pdf Provider Forms Order Form.

Electronic Claim Transaction Registration/Enrollment Forms 

Member Related Forms and Questionnaires

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 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 #P-23282 pdf 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 or the provider 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 or the provider 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.  

*View the medical policies associated with these drugs.

Physical Medicine Form 

Prior Approval Medical Forms 

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.

Referral Forms

To submit out of network and referral requests, use the online Utilization management tool. Please refer to the Quick Start Guide pdf.

Skilled Nursing Provider Forms




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