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Proveedores de Medicare

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Forms

Access key forms for authorizations, claims, pharmacy and more.

Disputes and Appeals & Grievances

Use this form to appoint an individual to act as a representative.

Use this form to file an appeal or dispute based on a claim outcome.

Wellcare Provider Payment Dispute Request Form

Non-Par Provider Payment Dispute Request Form

Wellcare Participating Provider Reconsideration Request Form

Non-Par Non Par Reconsideration Request Form

Authorizations

DME Authorization Request Form

Drug Prior Authorization Requests Supplied by the Physician/Facility

Requests for prior authorization (with supporting clinical information and documentation) should be sent to ʻOhana 14 days prior to the date the requested services will be performed.

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Other Provider Forms

Behavioral Health Forms

             Formularios de farmacia

We strive to cover the most common drugs across all conditions. Below are some common drugs not covered by the plan, along with alternative drugs that are covered. If your patient is currently on a drug that is not covered, please see if the formulary alternatives listed below would work for your patient.

Drug Prior Authorization Requests Supplied by the Physician/Facility

MCPB.ST.00: This policy provides a list of drugs that require step therapy effective January 1, 2025


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Last Updated On: 1/9/2025
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