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How the Process Works

Apply to Wellmark

To submit claims to Wellmark on behalf of your patients, you must apply to Wellmark. When you apply, you provide Wellmark with information needed to determine if your services are covered.  Wellmark does not cover services provided prior to a provider's effective date.

 

Wellmark uses your National Provider Identifier (NPI) to process claims. You must provide your NPI when enrolling with Wellmark.

 

Begin Wellmark's application process or review the process as described below.

Wellmark Reviews Your Application

Once you submit your application, Wellmark reviews the information and calls or sends a letter to gather any missing information. When required information is received, applications are reviewed.  In its sole discretion, Wellmark reserves the right not to process or accept a provider's application.

 

If you are applying for participation in a Wellmark network, your application will follow the credentialing process described below:

  1. Requirements checked - Wellmark makes sure you have a license in the state you're practicing, have liability insurance, and aren't being sanctioned, among other requirements. For additional requirements refer to the Contracts and Credentialing section  of the Wellmark Provider Guide.
  2. Credentialing Committee review - A committee of seven (six Wellmark providers and the Wellmark medical director) reviews your information and notifies you of its decision.
  3. Ongoing monitoring - During the three years that a practitioner is credentialed, Wellmark monitors any sanctions, citations, member complaints, or adverse events that occur.

The following practitioners are not required to credential with Wellmark, unless they wish to be listed in Wellmark's provider directory:

  • Physicians (specifically pathologists, radiologists, anesthesiologists, emergency room physicians, and hospitalists) and certified registered nurse anesthetists who meet all of the following requirements:
    • Practice exclusively within the inpatient hospital setting or a freestanding facility setting (such as mammography centers, urgent care centers and surgery centers)
    • Provide care for members only as a result of the members being directed to a participating facility
    • Are credentialed by a Wellmark participating facility
  • Residents who moonlight outside of their training program and have a full medical license (not a resident's license) can apply and be credentialed for the moonlighting situation. If the resident is moonlighting at the emergency department, the resident does not have to be credentialed but should apply to Wellmark.  If the resident is moonlighting in an in-network clinic, the resident must be fully credentialed with Wellmark. 

The following practitioners are not credentialed:

  • Hospital-based emergency room physicians are not credentialed by Wellmark.
  • Physical therapists, occupational therapists, advanced registered nurse practitioners, and telemedicine consultants who perform services in the hospital setting and whose services are billed using the hospital's NPI. Wellmark does not expect enrollment information for these providers because they are not identified for claim submission purposes.
  • Locum tenens practitioners who are in place for 60 days or less to provide coverage during the absence of a participating practitioner.  

Recredentialing

Recredentialing occurs every three years. If you are participating, Wellmark will send the recredentialing documents to you well in advance of your recredentialing due date. 

 

To avoid being terminated from Wellmark's provider network(s), you must complete the document and return to Wellmark within the timeframe identified in the notice.

Application Rules for Hospital-Based Practitioners

Hospital-based practitioners are radiologists, pathologists, anesthesiologists, certified registered nurse anesthetists, emergency room physicians, and hospitalists practicing exclusively in a hospital or other facility setting.  These practitioners need to apply to Wellmark.  However, depending on the situation, these practitioners may not need to execute a contract for participation with Wellmark.

 

Hospital Billing for Services

A hospital may have an employment or contracting relationship with some or all of their hospital-based providers. The practitioner services are submitted by the hospital to Wellmark using the hospital taxpayer ID number and NPI. Wellmark settles these claims directly with the hospital.

 

In this situation, the hospital executes a provider group agreement. If the hospital signs a group agreement with Wellmark, the provider does not need to execute an agreement. The hospital must provide a group list of all hospital-based providers (HBPs) covered under their group agreement. Each HBP on the group list should complete the application process if they have not already done so at a private practice location.

 

Provider or Provider Group Billing for Services

 

Some hospitals have a staffing arrangement with their hospital-based providers. As a part of this arrangement, the individual practitioner or group would contract direct with Wellmark. The individual or provider group bills for the professional component of the service using the appropriate individual or group taxpayer ID number and NPI to Wellmark members. Wellmark settles these claims directly with the individual provider or group.



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