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Forms

Access key forms for authorizations, claims, pharmacy and more.

Disputes and Appeals & Grievances

Use this form to appoint an individual to act as a representative.

Use this form to file an appeal or dispute based on a claim outcome.

Wellcare Provider Payment Dispute Request Form

Non-Par Provider Payment Dispute Request Form

Wellcare Participating Provider Reconsideration Request Form

Non-Par Non Par Reconsideration Request Form

Authorizations

DME Authorization Request Form

Drug Prior Authorization Requests Supplied by the Physician/Facility

Requests for prior authorization (with supporting clinical information and documentation) should be sent to ʻOhana 14 days prior to the date the requested services will be performed.

Telemedicine Authorization Request Form

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Behavioral Health Service Request Form

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

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Drug Prior Authorization Requests Supplied by the Physician/Facility

Request for Review of Medicare Prescription Drug Denial

This policy provides a list of drugs that require step therapy. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

This policy provides a list of drugs that require step therapy effective January 1, 2024. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

Other Provider Forms


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Y0020_WCM_87476E Last Updated On: 11/8/2022
On April 22, 2024, UnitedHealth Group issued a press release, providing an update on the Change Healthcare cybersecurity incident that occurred on Feb. 21, 2024. Given the size of the data impacted, the investigation to determine whose data is impacted is expected to take several months. UnitedHealth Group believes this situation will impact “a substantial proportion of people in America” and is offering immediate credit monitoring and identity protection services, as well as a dedicated contact center to address questions. Visit Change Healthcare Cyberattack Support and/or reach out to the contact center at 1-866-262-5342 regarding any questions.

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