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Provider Forms

Browse a wide variety of our most used forms. Can't find the form you need? Contact us for Iowa or South Dakota.

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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All network participation forms can be found on the Provider Credentialing page. Or, visit the credentialing Submission Tracker to track the status of your applications, recredentialing submissions and change requests.

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

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

Physical Medicine Treatment Plan (for anticipated services over 20 visits)

Begin the medical authorization process

  • Wellmark Health Plan of Iowa Chiropractic Referral form only PDF File
  • Problem List/Past Medical History Medical Record Keeping Aid #S-2600 PDF File

    • 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.

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