This page is a repository of forms and documents listed by function. The information is intended for use by Providers and Hospitals. Documents related to Member Services are included for your reference. If you have any questions, please contact our Provider Hotline at (866) 231-1821.        

Administrative Review

 Administrative Review Request Form - Member
 Administrative Review Request Form - Provider
 Appointment of Representative Statement
 Appeal Request Form for ER Med Review
 Complaint Request Form - Provider
 Grievance Form - Member
 PCP Request for Transfer of a Member

Authorizations

  Abortion Certificate of Necessity Form
 Ancillary Services Authorization Request Form
 Hospice ESRD Placement Referral Report
 Hysterectomy Information
 Hysterectomy Prior Receipt Acknowledgement Form
 Informed Consent for Voluntary Sterilization
 Inpatient Authorization Request Form
 OB Hospital Services Authorization and Notification Requirements Outpatient Authorization Request Form
 Prenatal Notification Form
 Provider Attestation for Outpatient Therapy Services
 PT, OT & ST for Children with Chronic Conditions
 Request for Referral/Certification

Billing Guidelines

  Federally Qualified Health Center Services (FQHC)/Rural Health Clinic (RHC)

Brochures

  All About WellCare
 Medical Management Objectives
 PaySpan Health - EFT/ERA Services
 Provider Responsibilities
 What is Managed Care?

Claims

 Applicable Co-Payments
 CMS 1500 Guidelines for Paper Claims
 CMS 1500 Submission Sample
 Coordination of Benefits Form
 Dental Claims / Encounter Guide
 ER Claims Reconsideration Form
 Institutional Claims / Encounter Guide
 Outbound Benefit Enrollment Guide
 Professional Claims / Encounter Guide
 Provider Information Update Form for Non-Participating Providers
 UB-04 Guidelines for Paper Claims
 UB-04 Submission Sample

"How To" Guides

Disease Management Program
 Filing an Administrative Review - Members
 Frequently Asked Questions
 Guide to Accessing Customer Service
 Pharmacy Services Guide
 Prenatal Notification & High-Risk OB Program
 Requesting an Authorization
 W-9 Contact Information
 Web Access
 WellCare's Web Capabilities

Member Services

 Incident Report
 Member Intervention Form
 Prenatal Reward Form

Pharmacy Services

 Accu-Chek® Order Form
 Abbreviated Preferred Drug List
 Abbott Meter Request Form
 Medicaid Coverage Determination Request Form
 Enternal Nutritional Supplement Form
 Injectable/Infusion Form
 Preferred Drug List
 Synaqis Order Form
 

Quick Reference Guides

Quick Reference Guide - Medicaid
No Authorization Required CPT Codes List
CPT Codes for Health Check/EPSDT Services 
 

Web Tutorials

 Electronic Funds Transfer (EFT) User's Guide
 Provider Portal Batch Eligibility Tutorial