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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 Transaction Registration/Enrollment Forms 
• Member Related Forms and Questionnaires
  • Personal Representative Appointment
• Network Participation Forms
• Paper Claim Forms 
• Pharmacy Forms
• Physical Medicine Forms 
• Prior Approval Medical Forms 
• Provider Claim Review Forms 
• Referral Forms 
• Skilled Nursing Provider Forms 
• Miscellaneous Forms 

Electronic Claim Transaction Registration/Enrollment Forms 

• Electronic Transaction Registration Packet #S-53260  
• Create and Submit Claims Submitter Number Registration Form for Wellmark Professional Claims #K-2307  
• Electronic Fund Transfers (EFT) & Electronic Remittance Advice (ERA)

  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.

• Electronic Fund Transfer (EFT) Form 
  • Frequently Asked Questions on EFT 
  • If you have questions regarding a missing or invalid EFT payment, please use the Ask & Track a Question  tool to submit an inquiry.
• Electronic Remittance Advice (ERA)/835 Enrollment Form  
  • If you have questions regarding a missing or invalid ERA, please use the Ask & Track a Question  tool to submit an inquiry.

Member Related Forms and Questionnaires

• Member Coordination of Benefits Questionnaire
  • Iowa  
  • South Dakota  

• Personal Representative Appointment

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

• Medical Claim Filing #CMS-1500  
• Facility Claim Uniform Bill #UB-04  
• Second Opinion Claim Form #C-4312 - Iowa only  
• Blue Dental Claim Form 

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 .
  • Your patient also has the option of contracting Wellmark Customer Service at the number printed on the back of his or her ID card.
• Prior Authorization Process
  • Please start by referring to the Pharmacy Prior Authorization page. There you will find an alphabetical listing of medications with Wellmark's corresponding pharmacy policy. If a medication is not listed, Wellmark does not maintain a pharmacy policy for it.
  • To download a global prior authorization form, please visit the CVS/caremark Prior Authorization page . 
• Specialty Pharmacy Programs
  • To enroll your patients in specialty pharmacy programs:
    • CVS/caremark - Enroll online  or call 800-237-2767 
    • Hy-Vee -  Enroll online  or call 877-794-9833

Physical Medicine Form 

• Physical Medicine Treatment Plan (for anticipated services over 20 visits)

Prior Approval Medical Forms 

• Prior Approval Form (To determine when to complete this form, visit Important Authorization Terms. These forms are only to be used for non-contracting or out-of-state providers. Contracting providers need to use the online Utilization Management Tool.)
  • Iowa - Medical #P-4602 
  • South Dakota - Medical #N-3614 
  • FEP (Federal Employee Program) Medical/Surgical Prior Approval Form #P-4306 

• Blue Distinction^® Centers for Transplant (BDCT forms are utilized by designated transplants facilities which participate with a local Blue Cross Blue Shield plan)

  • Transplant Services Notification 
  • Transplant Services Notification (Alternate Model) 
  • Hospital Notification of Transplant Admission 
  • Institution Billing Summary Form 

• Wellmark Health Plan of Iowa Chiropractic Referral Form Only 

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, use the online Utilization management tool. Please refer to the Quick Start Guide .

Skilled Nursing Provider Forms