Access key forms for claims, pharmacy and more. For information about prior authorization, please visit the Authorization page.
Appointment of Representative
Appointment of Representative Form Courtesy of the Department of Health and Human Services Centers for Medicare & Medicaid Services
Participating Provider Payment Dispute Form
Wellcare Provider Payment Dispute Request Form
Non-Par Provider Payment Dispute Form
Non-Par Provider Payment Dispute Request Form
Participating Provider Reconsideration Request
Wellcare Participating Provider Reconsideration Request Form
Non Par Provider Appeal Form
Non-Par Non Par Reconsideration Request Form
Provider Waiver of Liability (WOL)
Wellcare Provider Waiver of Liability (WOL) Statement Form
CMS 1500 Submission Sample
NDC Reporting Guidelines
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
Refund Check Information Sheet* (RCIS)
Refund Referral Grid
UB-04 Submission Sample
Please refer to NUBC (National Uniform Billing Committee – UB-04 forms) for complete detailed information about paper claim submission.
Adult New Member Physical
Complete within 90 days of enrollment
Immunization Record
Immunization Record Form
Medication Profile
Hepatitis C Treatment Prior Authorization Request
Hospice Information for Medicare Part D Plans
2024 Medicare Part B Step Therapy Criteria
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.
2024 Medicare Part B Step Therapy Criteria Policy
MCPB.ST.00: This policy provides a list of drugs that require step therapy. Updated July 31, 2024
Medical Drug Authorization Request
Drug Prior Authorization Requests Supplied by the Physician/Facility
Request for Medicare Prescription Drug Coverage Determination - Medicare
Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.
Request for Redetermination of Medicare Prescription Drug Denial
Fill out and submit this form to request an appeal for Medicare medications.
Cultural Competency Survey
Promoting Cultural and Linguistic Competency: Self-Assessment Checklist for Personnel Providing Primary Health Care Services.
Domestic Violence Screening Guidelines
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.
Incident Report
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.
Interpreter Services Request
We have resources available to provide assistance when you identify members who have potential cultural or language barriers.
PCP Request for Transfer of Member
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