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Medicare Providers

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Forms

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

Disputes, Reconsiderations and Grievances

Appointment of Representative Form Courtesy of the Department of Health and Human Services Centers for Medicare & Medicaid Services

Wellcare Provider Payment Dispute Request Form

Wellcare Participating Provider Reconsideration Request Form

Wellcare Provider Waiver of Liability (WOL) Statement Form

Authorizations

Behavioral Health Forms

Illinois Behavioral Health Forms


This document includes Harmony and WellCare covered services and authorization guidelines for Community Mental Health Center (CMHC) Services.

This document includes Harmony and WellCare covered services and authorization guidelines for Division of Alcoholism and Substance Abuse (DASA) Services.

Harmony/WellCare IET referral (Engagement Appointment)

Harmony/WellCare IET referral (Initial Appointment)

Claims

An NDC is required for pharmaceuticals that are dispensed from a pharmacy and physician-administered drugs in an office/clinic (i.e. FQHC/RHCs, dialysis facilities) or outpatient facility/hospital setting.

Refund Check Information Sheet* (RCIS)

Please refer to NUBC (National Uniform Billing Committee – UB-04 forms) for complete detailed information about paper claim submission.

Medical Records

Complete within 90 days of enrollment

Immunization Record Form

Medication Profile Form

Member Wellness Comprehensive Assessment Form

Pharmacy

Drug Prior Authorization Requests Supplied by the Physician/Facility

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.

Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.

Fill out and submit this form to request an appeal for Medicare medications.

Other Provider Forms

Promoting Cultural and Linguistic Competency: Self-Assessment Checklist for Personnel Providing Primary Health Care Services.

Within the managed care system, women are increasingly being seen in a primary care or obstetrician/gynecologist setting, which serves as their entry point into the health care system. The primary care visit offers a woman the chance to have a private conversation with her health care provider, where screening can be done in a less hectic setting than in the emergency department.

This report is to be completed for ALL injuries occurring within a facility. Report is to be printed and submitted to Risk Management within 24 hours of occurrence.

We have resources available to provide assistance when you identify members who have potential cultural or language barriers.

This form is intended solely for PCP requesting "Termination of a Member" (refer to Wellcare Provider Manual). Complete this request in its entirety and attach all supporting documentation, including pertinent medical records and office notes

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Last Updated On: 11/8/2022