Web request for redetermination of medicare prescription drug denial (appeal) (pdf) this form may be sent to us by mail or fax: Complete an appeal of coverage determination request (pdf) and send it to: (attach medical records for code audits, code edits or authorization denials. Do not attach original claim form.) Wellcare, medicare pharmacy appeals, p.o. Contact us, or refer to the number on the back of your wellcare member id card. Please do not include this form with a corrected claim. Access key forms for authorizations, claims, pharmacy and more. To access the form, please pick your state: Web claim” process in the wellcare by allwell provider manual, found on superiorhealthplan.com/providermanuals.
Please do not include this form with a corrected claim. Web medication appeal request form you can use this form to request an appeal when a medication coverage determination request has been denied. Access key forms for authorizations, claims, pharmacy and more. Complete an appeal of coverage determination request (pdf) and send it to: Send this form with all pertinent medical documentation to support the request to wellcare health plans, inc. Please do not include this form with a corrected claim. We have redesigned our website. An expedited redetermination (part d appeal) request can be made by phone at contact us or refer to the number on the back of your member id. Prior authorization request form (pdf) inpatient fax cover letter (pdf) medication appeal request form (pdf) medicaid drug coverage request form (pdf) notice of pregnancy form (pdf) provider incident report form (pdf) pcp change request form for prepaid health plans (phps) (pdf) What is the procedure for filing an appeal? To access the form, please pick your state:
