Provider forms

Medical appeals:

• Log in to the provider portal to access the Member Medical Appeal Form for Wellmark commercial members.
• Use the Medicare Advantage Provider Appeal Form for working with Medicare Advantage.
• Use the Provider BlueCard Claim Appeal form if you are appealing a BlueCard claim.

Pharmacy appeals:

• Providers may submit a Pharmacy Appeal Form, via fax, or mail.
• For additional information on the pharmacy appeals process, visit the pharmacy resources page.

• Medical Claim Filing #CMS-1500
• Facility Claim Uniform Bill #UB-04
• Second Opinion Claim Form #C-4312 - Iowa only
• Blue Dental Claim Form
• Blue Cross Blue Shield Global^® Core International Claim Forms*
  • English Version
  • Spanish Version

*The Blue Cross Blue Shield Global Core program was formerly known as BlueCard Worldwide^®

Begin the medical authorization process

• 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.
  • Iowa and South Dakota - Medical #P-4602
  • FEP (Federal Employee Program) Medical/Surgical Prior Approval Form #P-4306
  • In-patient Pre-Certification Form
  • FEP In-patient Pre-Certification Form
• Blue Distinction Centers for Transplant^®
  Note: These forms are utilized by designated transplants facilities that participate with a local Blue Cross Blue Shield plan.
  • Transplant Services Notification
  • Transplant Services Notification (Alternate Model)
  • Hospital Notification of Transplant Admission
  • Transplant Institution Billing Summary Form(s) - Find the forms in the Blue Cross Blue Shield Association BDCT Plan Manual
    • Transplant Institution Billing Summary Form – Attachment H Bone Marrow/Stem cell
    • Transplant Institution Billing Summary Form – Attachment H Solid Organ

You may fax the specific BDCT Transplant Institutional Billing Summary Form, including any BDCT Transplant claims or adjustments, to the BDCT Transplant Alert Team at 515-376-9074 or mail to Wellmark Blue Cross Blue Shield of Iowa, Mail Station 5E296, PO Box 9232, Des Moines, IA 50306-9232

• Personal Representative Appointment and Authorization to Release Protected Health Information
• Case Management/Care Coordination Consent template (for Part 2 SUD providers)

• Electronic Funds Transfer (EFT) Enrollment

• Pharmacy Appeal Form
• Brand Penalty Waiver Form
• Preventive Services Zero Copay Exception Form
• Personal Representative Appointment and Authorization to Release Protected Health Information Form
• CVS Global Authorization Form

For additional pharmacy information, visit the pharmacy resources page.

As of Jan. 1, 2026, physical medicine requests transitioned from the treatment plan process to prior authorization. Submit requests through Jiva, Wellmark’s electronic tool for managing medical authorizations. Visit the Medical Authorization Table and search for chiropractic therapy, physical therapy or occupational therapy to submit requests.

View the training webinar and find resources for using Jiva in the Wellmark Provider Portal. New to the portal? Log in now.

Log in to view Appeals and Inquiries 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.

• Provider Overpayment Inquiry Form
• Provider Overpayment Inquiry Form Instructions

• Skilled Nursing Facility Progress Report #N-2318416