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Forms

Below are the current versions of most common provider forms. Because these documents are subject to change, please do not stockpile printed versions for your office. Instead, please access these forms as needed from this page, printing only when absolutely necessary.

Electronic Claim Transaction Registration/Enrollment Forms

Wellmark uses Availity for electronic data interchanges (EDI) transactions including:

  • Electronic claim submissions (837)
  • Electronic remittance advices (ERA) (835)
  • Requests and responses for eligibility and benefits (270/271)

 

Log in to Availity

 

Don't have an Availity account? Register here .

Electronic Funds Transfers (EFT)

Wellmark participating providers have a contractual requirement to enroll in Electronic Funds Transfer. Please complete the Electronic Funds Transfer (EFT) Enrollment form.

 

Be sure to contact your financial institution(s) to make certain they are aware of the CAQH CORE (Council for Affordable Quality Healthcare, Committee on Operating Rules for Information Exchange) EFT and ERA operating rules. The appropriate arrangements will need to be made between you and your financial institution to accommodate the delivery of the CORE required minimum CCD+ (Cash Concentration or Disbursement including an addenda record) Data Elements necessary for re-association of the EFT payment with the ERA. CAQH CORE has developed a sample letter for providers to utilize when reaching out to their financial institutions. Please refer to the Committee on Operation Rules for Information Exchange for additional information pertaining to re-association.

 

Frequently Asked Questions on EFT pdf image

 

If you have questions regarding a missing or invalid EFT payment, please use the Ask & Track a Question tool to submit an inquiry.

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
    • If your patient needs a non-formulary drug, he or she may ask for an exception request. This process may allow coverage for those drugs not included in his or her drug list. To review this process, please visit the CVS Caremark® Prior Authorization page pdf.
    • Your patient also has the option of contacting Wellmark Customer Service at the number printed on the back of his or her ID card.
  • Drug Authorization Process
  • Specialty Pharmacy Programs
    • To enroll your patients in specialty pharmacy programs:

Physical Medicine Form 

Medical Authorization 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, submit an authorization. Please refer to the Quick Start Guide pdf.

Skilled Nursing Provider Forms


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