Get Provider Administrative Review Request Form

Filling out the Provider Administrative Review Request Form online is a straightforward process designed to facilitate the appeal of a claim decision. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your document editor.
2. Enter the request date on the form to indicate when you are submitting the appeal.
3. Indicate whether the service has already been provided by selecting 'Yes' or 'No'.
4. For the bundled request indication, choose either 'Yes' or 'No', if your appeal pertains to bundled services.
5. Select 'Yes' or 'No' for expedited request, if applicable. Review the definition of expedited request provided on the form.
6. Fill out the provider/appellant information, including the name and address for the provider, and the contact details.
7. Complete the patient information section, providing the patient's name, date of birth, and ID number.
8. Provide details about the service provided, including the date(s) of service and place of service.
9. In the reason for denial section, use the explanations on your Explanation of Benefits (EOB) letter to note the claim number and select the relevant reasons for denial from the provided options.
10. If applicable, fill out the clinical or claims appeal sections, choosing reasons appropriate to your appeal.
11. Clearly state the reason for your request in the designated area of the form.
12. Provide your signature and date to confirm your request and understand the payment terms outlined in the form.
13. Collect all necessary medical documentation to support your request and ensure it is attached.
14. Submit the form by sending it to WellCare Health Plans, Inc., either by mail or fax if fewer than 10 pages.
15. Finally, save changes made to your document and consider downloading, printing, or sharing the filled form for your records.

Complete the Provider Administrative Review Request Form online today to ensure your appeal is processed efficiently.