How a claim works
You visit your doctor (copays may be due at time of service). Your doctor sends your claim to Wellmark Blue Cross and Blue Shield. Wellmark sends you an Explanation of Benefits (EOB) and pays your doctor. Your doctor sends you a bill for the remaining balance. 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.
Or download the form and submit by mail:
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
If you would like to appeal a denied claim to see if a different outcome is possible, you must file a written appeal within 180 days of the date of the decision. If the situation is medically urgent, your doctor can call to make a verbal appeal.
To appeal a claim in Iowa or South Dakota, file your appeal on myWellmark or download, print and mail the completed Wellmark medical member appeal form to:
Wellmark Blue Cross and Blue Shield
Special Inquiries & Appeals
P.O. Box 9232
Des Moines, IA 50306-9232
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 claim types 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.
Request an Iowa External Review
Request a South Dakota External Review
If your health insurance is supplied through a self-funded group located in South Dakota, please use the South Dakota External Review Request Form.