Medicare Advantage Request Form For Appeal - Wellmark

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Provider Post Service Appeal Form
(Please complete one form per patient)
Please Note: You are not eligible to request an appeal on pre-service matters. Only a member may appeal pre-service
matters. If you wish to request a pre-service appeal on behalf of a member, you will need to follow the member appeal
process and be appointed by the member as an authorized representative. The Authorized Representative Appointment
form is available on at:
Note:
c Before submitting a post-service appeal, you must have submitted and received an answer to a provider inquiry on the
claim in question.
c An appeal must be received by Wellmark within 180 days of the remittance date of the claim in question.
c To submit an appeal, complete the entire form and attach pertinent information related to the service/claim in question,
such as office notes, operative report, etc. Incomplete appeal submissions will be returned unprocessed.
c Mail this form and the supporting information to:
Wellmark Blue Cross and Blue Shield of Iowa
Provider Appeals, Station 5W190
PO Box 9232
Des Moines, Iowa 50306-9232
or fax to: 515-376-9073
Required Member Information
Member ID#: ________________________________________
Member Name: _______________________________________ Patient Name: __________________________________
Last
First
Last
First
Required Claim Information
List Claim Number(s) Below
Date(s) of Service
Total Charge Amount(s)
Required Provider Information
Wellmark Provider#: _______________________________
Provider Name: _________________________________
Provider Address: __________________________________
City: ___________________ State: ______ Zip: _______
Provider Contact Person: ____________________________
Contact Telephone#: _____________________________
Provider Fax#: _____________________________________
Please provide an explanation of your appeal and attach any and all documentation that may assist us in our review. Use
separate sheets if additional space is necessary. For information specific to Wellmark’s Medical Policies you may search by
keyword or by CPT code at:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Operative Report
c Yes, Number of addt’l pgs. _____
c No
Did you attach:
Chart Notes
c Yes, Number of addt’l pgs. _____
c No
Other Information
c Yes, Number of addt’l pgs. _____
c No
S-53259 10/15

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