Wellmark uses Availity for electronic data interchanges (EDI) transactions including:
- Electronic claim submissions (837)
- Electronic remittance advices (ERA) (835)
- Requests and responses for eligibility and benefits (270/271)
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- Member Coordination of Benefits questionnaire
- Personal Representative Appointment PDF File
- Case Management/Care Coordination Consent template PDF File (for Part 2 SUD providers)
- Medical Claim Filing #CMS-1500 External Link
- Facility Claim Uniform Bill #UB-04 External Link
- Second Opinion Claim Form #C-4312 PDF File - Iowa only
- Blue Dental Claim Form PDF File
- Blue Cross Blue Shield Global Core International Claim Forms*
- Member Acknowledgment of Financial Responsibility Waiver Secure Site
*The Blue Cross Blue Shield Global Core program was formerly known as BlueCard Worldwide®
Pharmacy exception requests for non-formulary medications
- If your patient needs a non-formulary drug, he or she may ask for an exception request. This process may allow coverage for those drugs not included in his or her drug list. To review this process, please visit the CVS Caremark® Prior Authorization External Link page. Your patient also has the option of contacting Wellmark Customer Service at the number printed on the back of his or her ID card.
Drug authorization process
- Please start by referencing the drug authorization list. Use the drug authorization table to see a list of Wellmark's drug policies. If a drug is not listed, Wellmark does not maintain a policy for it.
- Prescribing providers may also use the CVS Caremark Global Prior Authorization form External Link page.
Specialty pharmacy programs
- To enroll your patients in specialty pharmacy programs:
Request for waiver of brand penalty
- Depending on your patient’s benefits, if a brand drug is filled when a generic alternative is available, your patient will pay their copay or coinsurance plus the cost differential between the generic and brand drug. You may submit a request for your patient to receive the brand-name drug when a generic alternative is available and only pay the applicable cost-share by using the Request for waiver of brand penalty form PDF File.
Preventive services contraceptive zero copay exception
- In accordance with Patient Protection and Affordable Care Act requirements, providers may request a zero-dollar coverage exception review for contraceptives when the requested drug is medically necessary to prevent pregnancy. Submit by fax using the preventive services contraceptive zero copay exception form PDF File, through CoverMyMeds, or call to request an exception.
Physical Medicine Treatment Plan (for anticipated services over 20 visits)
- Prior Approval form Note: To determine when to complete this form, visit Types of Authorizations. These forms are only to be used for non-contracting or out-of-state providers. Contracting providers need to use the online authorization tool.
- Blue Distinction® Centers for Transplant Note: These forms are utilized by designated transplants facilities that participate with a local Blue Cross Blue Shield plan.
Log in to view Appeals and Inquiries Secure Site information.
Note: The post-service provider appeal process does not apply to overpayment recovery requests. If you have received an overpayment recovery request and do not agree with our reasons for requesting the refund, submit an overpayment recovery appeal.
To submit out of network and referral requests, submit an authorization. Please refer to the Jiva quick guide for submitting out of network (OON) requests Secure Site.