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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.

Telemedicine Authorization Request Form

Salud conductual

Behavioral Health Service Request Form

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Farmacia

Drug Prior Authorization Requests Supplied by the Physician/Facility

Request for Review of Medicare Prescription Drug Denial

This policy provides a list of drugs that require step therapy. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

This policy provides a list of drugs that require step therapy effective January 1, 2024. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

Other Provider Forms


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Last Updated On: 11/8/2022
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