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  • Provider Appeal Request Form - Wellcare

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Provider Appeal Request Form Staywell WellCare Commercial WellCare Choice HealthEase Healthy Kids Request Date: Has the service been provided yet? Expedited Request? Yes No Yes No (See reverse side.

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The Claim Payment Dispute Process is designed to address claim denials for issues related to untimely filing, unlisted procedure codes, non-covered codes etc. Claim payment disputes must be submitted in writing to Wellcare within 90 calendar days of the date on the EOP.

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.

A provider has the greater of 180 days from The Health Plan's denial or 180 days from the date of service to request a reconsideration.

You or your provider must call or fax us to ask for a Expedited Appeal. Call us at 1-877-389-9457 (TTY 711 or 1-877-247-6272). Or fax it to 1-866-201-0657. If you file your Expedited Appeal by phone, written notice is not needed.

You must file your appeal within 60 calendar days from the date on the Notice of Adverse Benefit Determination (letter) we send you. You may file your appeal by phone or in writing. If you file your appeal by phone, you must send us a written, signed notice (appeal letter) within 10 calendar days of your phone call.

You have 60 calendar days from the date of the Initial Benefit Determination notice to file an appeal. You can call Customer Service at 1-800-288-5441 (TTY 711) for help filing a Plan Appeal.

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.

You have 60 calendar days from the date of the Initial Benefit Determination notice to file an appeal. You can call Customer Service at 1-800-288-5441 (TTY 711) for help filing a Plan Appeal.

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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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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:
1-877-389-0141
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