Claims & Appeals
How a claim works
1) You visit your doctor. Copays may be due at time of service. 2) Your doctor sends your claim to Wellmark. 3) Wellmark sends you an EOB. 4) Wellmark pays your doctor. 5) Your doctor sends you a bill for the remaining balance. 6) You pay your doctor.
Submit a claim
In most cases, your in-network health care provider will submit claims on your behalf, but if you recently received care from an out-of-network provider, you may need to submit a claim to be considered for reimbursement of services covered by your benefits. Working with your doctor will be the easiest way to fill out the form.
If your claim is denied
Claims may be denied for a number of reasons. If you have already reviewed your Explanation of Benefits (EOB) and don't fully understand the reason for the denial, you can contact Wellmark Customer Service and we will walk you through the reason.
File a claims appeal for review by Wellmark
Sometimes you might disagree with a claim being denied. You can work through the appeal process to find out if a different outcome is possible. 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.
Download a claims appeal form to get the process started.
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.