Contact Us
Home Provider Communications and Resources
» Working with Wellmark.com
» News
» Blue Card
» Claims and Payment
» Medical Policies and Authorizations
» Health Management
» Medical, Dental, and Pharmacy
» Credentialing and Contracting
» Quality and Transparency
» Communications and Resources
» Health Care Reform for Providers
printer friendly Printer-Friendly Page
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 

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 contracting Wellmark Customer Service at the number printed on the back of his or her ID card.

Pharmacy 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 pdf

 

To enroll your patients in specialty pharmacy programs:

CVS/caremarkEnroll online pdf or call 800-237-2767 

Hy-Vee -  Enroll online pdf or call 877-794-9833

Physical Medicine Form 

Prior Approval Medical 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, use the online Utilization management tool. Please refer to the Quick Start Guide pdf.

Skilled Nursing Provider Forms


Register now

[X]

I need secure access to:

Tools and resources related to:

  • Claims
  • Payment
  • Benefits
  • Utilization Management

Take me there.

Or

E-credentialing Central to access these tools:

  • Application Tool (coming soon)
  • Change Request Tool
  • Recredentialing Tool
  • Provider Directory Update Tool (coming soon)
  • Submission Status Tracker
  • Submission History Tool
  • View my Organization
  • Manage my Users

Take me there.


Quick Links

» Authorization Table
» Submission Status Tracker
» Drug Information
» Education
» Find a Doctor or Hospital
» Forms
» Health Care Reform
» ICD-10
» Medical Policies
» Provider Guide
» WINS
FacebookTwitterInstagrampinterestLinked InYou Tube