A few things to know if you're:
Current Wellmark members
To help you make the best decision for you and your family, this information explains your rights as a member, and the protection you expect from Wellmark.
As a member, it’s important that you know your rights and responsibilities. This can help you make informed health care decisions and have more control over your well-being.
Your information is secure
Patient privacy is essential to obtaining high quality health care. The HIPAA Privacy Rule to Support Reproductive Health Care Privacy safeguards the protected health information of an individual so that it cannot be used or disclosed to investigate or impose liability for the mere act of seeking, obtaining, providing, or facilitating legal reproductive health care. Because by protecting your privacy, we can protect your health. Wellmark has updated our privacy practices, our legal duties and your rights concerning your protected health information.
To find out how your medical information may be used and disclosed, review Wellmark's Privacy Practice Notice.
You may request a copy of our privacy notice at any time by calling our toll-free number at 877-610-6395.
If you’re enrolled in a Qualified Health Plan (QHP), as defined by the Affordable Care Act (ACA), you can choose to exchange your health information with apps, providers and other insurers, which could help improve your health care experience.
If for some reason, a claim is denied, partially-denied or covered by a reduced payment, you can request a review through our Claims Appeal and External Review Process.
The right to appeal and the external review information is also available when reviewing a claim in myWellmark®.
No one plans to get injured or become sick. But if you or a family member has a medical issue serious enough to need quick attention, urgent care may be the answer.
In a medical emergency, get qualified help immediately.
Every Blue Cross Blue Shield plan participates in the BlueCard® program, which allows Wellmark members access to their plan benefits anywhere inside the U.S. Depending on the type of plan you have, you may only be covered in emergency situations. That's why it's important to register for and log in to myWellmark to check your benefits before receiving care.
To ensure that our members have access to the best possible care, we regularly review the latest procedures, drugs, devices and methods.
How we evaluate new technology
We regularly review the latest procedures, drugs, devices, and methods to determine which treatments will improve medical outcomes. The task of determining when the new is appropriate and the old is no longer acceptable is complex. It involves research, reviewing members' claims and many other processes.
The Technology Evaluation Center (TEC), a program of the Blue Cross and Blue Shield Association, is a valuable tool we use to evaluate new technology. TEC provides scientific analysis and opinions that advance the understanding of complex technology issues. Wellmark uses criteria established by TEC in the development of new medical policy:
- The technology must have final approval from the appropriate government regulatory bodies. All new devices and technologies, with the exception of new procedures, require approval from the Food and Drug Administration.
- The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
- The technology must improve the net health outcome.
- The technology must be as beneficial as any established alternatives.
- The improvement must be attainable outside the investigational settings.
If you or your physician need more information regarding whether Wellmark covers a new technology or if you would like to submit a request to have new technology reviewed, call the Customer Service number on your Wellmark ID card.
Need your Wellmark ID card? Get it.
When you are enrolled in a Wellmark health plan, you will be able to find answers to many important questions in the appropriate Summary of Benefits and Coverage (SBC) or a more in-depth information can be found in the appropriate coverage manual.
Within your coverage manual, you can find information on:
- Covered and non-covered benefits in the "Details - covered and not covered" section
- Copayments and other charges in the "Factors affecting what you pay" and "What You Pay" sections
- How to file a claim in the "Claims" section
- Practitioner and provider availability, as well as out of service area, in the "Choosing a Provider" section
- How to obtain primary care, specialty care, behavioral health care along with hospitals and after hours care, in the "Choosing a Provider" and "Details-Covered & Not Covered" sections
- Utilization management procedures in the "Notification Requirements and Care Coordination" section
- Potential network, service or benefit restrictions in the "Choosing a Provider" section
- How to submit a complaint in the "General provisions" section
To view your coverage manual or summary of benefits and coverage by:
- Searching our public SBC and Coverage Manual Finder
- Logging in to myWellmark
- Contacting Customer Service
Quality at Wellmark is part of everything we do. We are committed to quality by working with providers to keep you healthy, creating healthy communities and providing tools, resources and programs to help you manage your health and spending. Wellmark is also accredited by National Committee for Quality Assurance (NCQA), a non-profit organization dedicated to improving health care quality.
You can rest assured knowing coverage decisions are based on the medical appropriateness of care, services, and your benefit plan. To make sure you receive the highest quality and safest care:
- Wellmark does not reward providers for denying services
- Wellmark does not reward coverage decisionmakers for decisions that result in a denial of coverage or service
Case management programs help support members by managing chronic medical conditions and diseases, ongoing health maintenance and preventive services. These programs also provide care coordination, which includes the use of health care services, continuity of care and care coordination across health settings.
Wellmark's Case Management Program
When faced with a serious diagnosis, multiple conditions or complex conditions, you and your family have many tough choices to make. Wellmark's Case Management Program can help you navigate the health care system and provide support during your time of need.
To learn more about Wellmark's Case Management Program, call 800-552-3993 or log in to myWellmark. You can also get health questions answered through our BeWell 24/7® Nurse Support program by calling 844-842-3935.
Prospective Wellmark members
Need to know if a medical procedure or service is covered? Have questions about prescription drug benefits? Need to see if your current providers are in-network? You will be able to find answers to many important questions in the appropriate Summary of Benefits and Coverage (SBC). An SBC is a quick overview of what the health plan benefits include.
For an in-depth, complete guide to everything a health plan includes or excludes, the Coverage Manual will have the information. It describes the plan’s coverage details and how the health plan works. It also will explain covered benefits, non-covered benefits, practitioner and provider availability, utilization management procedures, network, service or benefit restrictions, prescriptions and drug list and more.
Within your coverage manual, you can find information on:
- Covered, non-covered benefits in the “Details – covered and not covered” section
- Practitioner and provider availability, as well as out of service area, in the “Choosing a Provider” section
- Utilization management procedures in the “Notification Requirements and Care Coordination” section
- Potential network, service or benefit restrictions in the “Choosing a Provider” section
- Pharmacy and Drug Lists in the “What you pay” and “Factors Affecting What You Pay” sections
To view a coverage manual or summary of benefits and coverage (SBC) search our public SBC and Coverage Manual Finder using the general search feature.