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  • Staywell Appeal Form

Get Staywell Appeal Form

Ment at P.O. Box 31368 Tampa, FL 33631-3368. You may also fax the request if less than 10 pages to (866) 201-0657. Your appeal will be processed once all necessary documentation is received and you will be notified of the outcome. Ohana Health Plan Request Date: Has the service been provided yet? Yes No Expedited Request? Yes No (See reverse side for definition of Expedited Request) Provider/Appellant Information Patient Information Name.

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Claim payment disputes must be submitted to WellCare through the provider portal or in writing within 90 days of the date of denial on the EOP.

Claim payment disputes must be submitted in writing to Wellcare within 90 calendar days of the date on the EOP. Submit all claims payment disputes with supporting documentation at https://provider.wellcare.com/.

Filing an Appeal Appeals can be submitted in writing within 30 calendar days of the date of the Explanation of Payment or the Provider Administrative Denial letter.

Please note: If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim, you should submit a corrected claim within 180 days of the date of service or discharge. You do not need to file an appeal.

Timely Filing Requirements: All claims must be received by the plan within six (6) months from the date the service was provided in order to be considered for payment. Claims received after this time frame will be denied for failure to file timely.

Attn: Appeals Department, P.O. Box 31368 Tampa, FL 33631-3368. This form is to be used when you want to appeal a claim or authorization denial. Fill out the form completely and keep a copy for your records. Send this form with all pertinent medical documentation to support the request to WellCare Health Plans, Inc.

Appeals must be submitted in writing within 90 calendar days of the date of the Explanation of Payment or the Provider Administrative Denial letter. If you have questions and/or concerns about the appeals process, please contact Provider Services for assistance.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232