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How the Process Works

Step 1: Enrolling with Wellmark

To provide services that can be considered for Wellmark benefits, eligible providers must enroll with Wellmark. 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.

Refer to the following table to begin Wellmark's enrollment process:

If ...	Then ...
You are an eligible provider seeking Wellmark network participation	Complete one of the following applications: South Dakota Uniform Application  (2.3MB) Professional Provider Application - #B-3308  (581KB)
You are an eligible provider who does not wish to participate in Wellmark's networks	Complete the Professional Provider Application - #B-3308  (581KB) to obtain a provider number to submit claims.
You have completed the South Dakota Uniform Application for another payer, managed care organization (MCO), or other entity	Complete the Wellmark Addendum included as part of the South Dakota Uniform Application  (2.3MB).   Include the completed South Dakota Uniform Application  (2.3MB).

Step 2: Reviewing Your Application

Wellmark reviews your application and calls or sends a letter to gather any missing information. Once all the required information is received, applications for providers wishing to enroll with Wellmark will follow the credentialing process:

1. Credentialing criteria review  (25KB) - Wellmark makes sure you have a license in the state you're practicing, have liability insurance, and aren't being sanctioned, among other requirements.
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 within 60 days.
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, and emergency room physicians) 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
• 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.  
• Residents moonlighting outside of their training program who have a full medical license (not a resident's license) can be credentialed for the moonlighting situation. Otherwise, residents are not recognized practitioners and cannot credential with Wellmark.

Recredentialing

Recredentialing occurs every three years.

Step 3: Understanding the Rules for Hospital-Based Providers

Radiologists, pathologists, anesthesiologists, certified registered nurse anesthetists, and emergency room physicians practicing exclusively in a hospital , or other facility setting , may not need to execute a direct agreement with Wellmark.

Hospital Billing for Services

In many instances, the hospital has an employment or contracting relationship with some or all of their hospital-based providers (HBPs). The hospital bills Wellmark using the hospital taxpayer ID number and NPI for services provided to Wellmark members by the HBPs. Wellmark settles these claims directly with the hospital.

In this situation, the hospital may choose to execute a provider group agreement for these services. The provider does not need to execute an agreement if the hospital signs a group agreement with Wellmark. 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.

Hospitals are not required to contract with Wellmark on behalf of their hospital-based providers. If the hospital does not contract for their HBPs, the HBPs must sign either a direct or a group agreement with Wellmark in order to participate in Wellmark networks.

Provider or Provider Group Billing for Services

In other instances, the hospital has a staffing arrangement with their HBPs. As a part of this arrangement, the individual provider or group would contract directly with Wellmark. The individual or provider group would also bill for the professional component of the service provided to Wellmark members using the appropriate taxpayer ID number and NPI. Wellmark settles these claims directly with the individual provider or group.

In this situation, Wellmark will pursue a contract directly with the provider or the provider’s group, Provider Hospital Organization or Provider Organization.