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 will not cover services provided prior to your effective date.
Participation option: To receive added benefits, you may participate in one or more networks by signing a contract with Wellmark.
Note for hospital-based providers: You may save time by reviewing Application - Rules for Hospital-Based Providers before proceeding.
Begin Wellmark's application process or review the process as described below.
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:
The following practitioners are not required to be credentialed by Wellmark unless they wish to be listed in Wellmark's provider directory:
The following practitioners are not credentialed:
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.
Hospital-based practitioners are radiologists, pathologists, anesthesiologists, hospitalists, certified registered nurse anesthetists, and emergency room physicians 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 practitioners. The practitioners’ services are submitted by the hospital to Wellmark using the hospital taxpayer ID number and NPI. Wellmark settles these claims with the hospital.
In this situation, the hospital executes a provider group agreement. If the hospital signs a group agreement with Wellmark, the practitioner does not need to execute a participating agreement. However, the hospital must provide a group list of all hospital-based practitioners who are covered under their group agreement. Each practitioner on the group list:
Practitioner 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. Wellmark settles these claims with the individual practitioner or group.