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Medicare Providers

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Forms

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


Appeals & Grievances

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

Use this form to dispute a provider payment.

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

Authorizations

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

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Please complete ALL FIELDS and fax this form to WellCare’s Pharmacy Department at 1-866-388-1767.

Other Provider Forms


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Last Updated On: 5/9/2017
Starting January 1, 2019 `Ohana Health Plan will offer adult dental coverage. Read more. ×