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Enrollment of Facilities/Entities

Apply for Participation: Enrollment Forms

(continued from Eligibility)

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Step 5) Wellmark accepts the Iowa Statewide Universal Facility Application (Directions) for both entities and facilities.

Completing the Application

Wellmark accepts participation applications you previously completed for other insurers as long as:

• The information provided is current within the last 30 days, and
• The provider has re-signed the certification and release statement.

Missing information will slow the application process, so please:

• Read the application thoroughly and complete all questions.
• Include your National Provider Identifier (NPI).
• Complete all non-applicable using an "N/A" or other appropriate indicator.
• Verify the application is signed and include all requested document copies.

Step 6) Print and complete the W-9 Federal Tax Identification Form.

Step 7) If you can or would like to submit claims electronically, complete the Electronic Claims Form. Once completed, print and continue to the next Step. Providers who do not have the ability or desire to file claims electronically, should also continue to the next Step.

Step 8) Hospitals, Skilled Nursing Facilities and Psychiatric Medical Institutes for Children must provide financial documentation in order for Wellmark to calculate payment rates. If the application is for one of these facility types, complete and print the Facility Application Supplement Provider Economics Information form and provide the requested documentation. Continue the enrollment process at the next step.

Ambulatory Surgery Centers, Dialysis Centers, Free-standing Substance Abuse Facilities, Home Health Agencies, and Hospice providers must complete and print the Facility Application Supplement Provider Economics Information form for reimbursement information to be appropriately tied to your facility. Continue the enrollment process at the next step.

Important Note: You should not file claims for any Wellmark members until you have been notified of your approval for a specific network. Furthermore, you should not provide services for any Wellmark HMO member prior to receiving notice of your acceptance to the HMO network. Claims for services provided prior to this date will be denied unless a referral was approved in advance.

If you are interested in submitting claims and do not wish to participate, continue to Submitting Your Enrollment Forms.

If you are interested in participating in a Wellmark network, continue to Participation Agreements .

Copyright© 2008 Wellmark, Inc. All Rights Reserved.
Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.