Get Wellcare Of Ny Reimbursement Form

Filing a reimbursement request through the Wellcare Of Ny Reimbursement Form is a straightforward process that allows users to reclaim costs incurred for covered prescription drugs. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to fill out the form successfully.

1. Click ‘Get Form’ button to obtain the Wellcare Of Ny Reimbursement Form and open it in your digital editor.
2. Begin by entering your member information. Fill in your name, date of birth, ID number, street address, apartment/unit number, phone number, city, state, zip code, and client ID. Ensure all details are accurate and up-to-date.
3. Indicate the reason for your request by selecting one of the options provided such as 'No identification card available', 'Out of network pharmacy used', 'Emergency', 'Copayment inquiry', or 'Pharmacy unable to process claim electronically'. If necessary, provide additional details in the space provided.
4. Provide the pharmacy and prescription information. Attach the detailed prescription label receipts and enter the information required in the designated fields. Include the drug name, date of fill, quantity, days supply, amount paid, NDC (National Drug Code), doctor's name, doctor's NPI (National Provider Identifier), pharmacy NPI, and RX number for each prescribed medication.
5. Double-check the readability of all information on the prescription label receipts you are submitting, as illegible documents may result in delays or denials of your claim.
6. Affirm your understanding by signing the enrollee signature section. Complete the date next to your signature. If you are signing on behalf of another person, ensure you have the authorization to do so under state law.
7. Once you have completed the form, save your changes and prepare to submit the form along with the original prescription label receipts. You can download, print, or share the completed form as needed.
8. Mail your completed form and receipts to WellCare's Reimbursement Department at the provided address. Be certain to check that all required documentation is included.

Take action now and complete your Wellcare Of Ny Reimbursement Form online for a seamless reimbursement process.