Get Wellmed Appeal Form

This guide provides clear instructions for completing the Wellmed Appeal Form, tailored to assist users in navigating the online process efficiently. By following these steps, you will ensure your claim reconsideration request is completed accurately and submitted properly.

Follow the steps to complete the Wellmed Appeal Form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill out the member information section. Include the date the form is completed, member ID, control/claim number, date of service, billed amount, and member's last name, first name, and middle initial.
3. Provide the street address, state, and zip code for the member as well as the patient's name, including last name, first name, and middle initial.
4. In the physician/health care professional information section, enter the tax identification number (TIN), phone number, and email address.
5. Include the name of the physician or health care professional as listed on the Explanation of Payment (EOP). Fill in their last name, first name, middle initial, street address, state, and zip code.
6. List the facility or group name and the contact person's name.
7. Indicate the option amount owed and choose the reason for your request from the provided options, ensuring to check the relevant box.
8. Clearly state what you expect from WellMed Medical Management to resolve this claim reconsideration, including a dollar amount if applicable.
9. Add any comments that may help clarify your request.
10. Gather and attach the required documents, including a copy of the EOP, and any other necessary attachments as indicated.
11. Once you have completed all sections and attached required documents, save your changes. You may also download, print, or share the form as needed.

Complete your Wellmed Appeal Form online today to ensure your claim reconsideration is processed efficiently.