How to file a Claim
If you recently received care from an out-of-network provider, you can submit a claim to be considered for reimbursement of services covered by your benefits.
Medical authorization may help keep costs down
Some services or hospital stays may require authorization to avoid additional out-of-pocket costs. If your service requires authorization or you think it may, call the phone number on the back of your ID card to get the authorization process started.
Submit your claim
Submit the form to get reimbursed for covered care or prescription drugs received from an out-of-network provider. Work with your doctor to fill out the form.Submit your claim form electronically opens in new window Claim form - English PDF File Claim form - Spanish PDF File
File a claims appeal for review by Wellmark
If you disagree with a benefit decision, you may use this form to request a review by Wellmark.
Written appeals must be filed within 180 days of the date of the decision. If the situation is medically urgent, your doctor can call to make a verbal appeal.
File Iowa Appeal PDF File File South Dakota Appeal PDF File
File a request for external review
You may have the right to request a review by an independent organization.
If you have gone through your options to appeal a denial of coverage or benefits and disagree with the decision, your written notice will tell you if an external review is available. An external review may not be available for all members or for all types of claims and is not available for Medicare supplement plans or most dental plans.
An expedited external review process is available if you have a medical condition where a delay in treatment could seriously jeopardize your health, life or ability to regain maximum function.