How to file a Claim
You only need to submit claims if you get care or prescription drugs from an out-of-network provider. To avoid additional out-of-pocket expenses, you may need to get pre-approval before a service or hospital stay. Just call the phone number on your ID card.
If Your Claim is Denied
Claims may be denied for a number of reasons. Your first stop should be to contact customer service so we can investigate and explain the reason why. If you still have questions, we've put together a process to help you with the next steps. For a full review of a denied claim, follow either the Claims Appeal or External Review Process. Both are detailed here.
File a Claims Appeal for Review by Wellmark
Written appeals must be filed on Iowa or South Dakota Wellmark Appeal/Review Forms within 180 days of the date of the decision. If the situation is medically urgent, you can call us to make a verbal appeal.File Iowa Appeal PDF File File South Dakota Appeal PDF File
File a Request for External Review
If you’re still unsatisfied with our review, you may have the right to ask for another review by the state of Iowa or South Dakota. You may submit a written request for an external review of your claim denial through the appropriate state insurance division.
If you have a medical condition where a delay in treatment could seriously jeopardize your health, life or ability to function, an expedited External Review process is available. Contact your state insurance division for details.
NOTE: External review may not be available for all members or for all types of claims, and is not available for Medicare supplement or most dental plans.