Loading
Get 866 388 1767
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the 866 388 1767 online
Filling out the 866 388 1767 form for Medicare prescription drug coverage determination can be straightforward with the right guidance. This user-friendly guide offers a step-by-step approach to ensure you complete the form accurately and effectively.
Follow the steps to successfully complete your form.
- Click the ‘Get Form’ button to access the form and open it in your preferred editor.
- Provide the enrollee's information, including their name, date of birth, address, city, state, zip code, phone number, and member ID number. Ensure all details are accurate and complete.
- If the request is being made by someone other than the enrollee or the prescriber, fill out the requestor's section with the necessary details, including their name, relationship to the enrollee, address, city, state, zip code, and phone number.
- If applicable, attach any representation documentation showing authority to represent the enrollee. This could be an Authorization of Representation Form CMS-1696 or equivalent documentation.
- Indicate the name of the prescription drug you are requesting, including the strength and quantity required per month, if known.
- Select the type of coverage determination request that applies to your situation. There are several options, such as formulary exceptions, prior authorizations, and tiering exceptions. Make sure to understand each option and select accordingly.
- Provide additional information and attach any supporting documents if necessary, especially for requests requiring a prescriber’s supporting statement.
- If your prescriber believes an expedited decision is necessary, make sure to check the appropriate box and attach their supporting statement.
- Ensure the person requesting the coverage determination signs and dates the form.
- Review your completed form for accuracy, then save changes, download, print, or share as needed.
Complete your documentation online now to help ensure timely processing of your request.
Timely filing for Wellcare claims outlines the period in which a claim must be submitted to be considered for payment. This is usually within 90 days of the service date. To avoid delays and ensure that your claims are processed efficiently, consider reaching out to us at 866 388 1767 for further clarification and assistance.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.