Because these documents are subject to change, please do not stockpile printed versions for your office. Instead, please access these forms as needed from this page, printing only when absolutely necessary. Electronic Claim Transaction Registration/Enrollment Forms Member Related Forms and Questionnaires. Network Participation Forms All forms regarding network participation are available at our Credentialing and Contracting page. On our page, you will also find the Credentialing Submission Tracker where you are able to track the status of your applications, recredentialing submissions, and change requests. Paper Claim Forms. MSU Benefits Committee Reports MSU Benefits and IUBC Reports (for years prior to FY05, please see Staff Senate meeting Minutes) Membership. Anthem is a trusted health insurance plan provider. Visit and compare our health care, dental, vision and Medicare plans today. Pharmacy Forms. Pharmacy exception requests for non- formulary medications. If your patient needs a non- formulary drug, he or she may ask for an exception request. This process may allow coverage for those drugs not included in his or her drug list. To review this process, please visit the CVS/caremark Prior Authorization page . Your patient also has the option of contracting Wellmark Customer Service at the number printed on the back of his or her ID card. Pharmacy Prior Authorization Process. Please start by referring to the Pharmacy Prior Authorization page. There you will find an alphabetical listing of medications with Wellmark's corresponding pharmacy policy. If a medication is not listed, Wellmark does not maintain a pharmacy policy for it. To download a global prior authorization form, please visit the CVS/caremark Prior Authorization page . To enroll your patients in specialty pharmacy programs: CVS/caremark - Enroll online or call 8. Hy- Vee - Enroll online or call 8. Physical Medicine Form Prior Approval Medical Forms Provider Claim Review Forms. For guidance, please visit the Appeals and Inquiries page. Note: The post- service provider appeal process does not apply to overpayment recovery requests. If you have received an overpayment recovery request and do not agree with our reasons for requesting the refund, submit an overpayment recovery appeal. Referral Forms. To submit out of network and referral requests, use the online Utilization management tool. Please refer to the Quick Start Guide . Skilled Nursing Provider Forms.
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January 2017
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