Advance Coverage Determination

To be used to obtain a written advance coverage determination (also known as an organization determination) from us before furnishing a service in order to confirm whether the service is medically necessary and will be covered by WellCare PFFS.

Appointment of Representation Form

To be used when acting on behalf of a member in connection with a claim or an asserted right under Title XVIII of the Social Security Act (the “Act”) and related provisions of Title XI of the Act.

Provider Claim Payment Resolution Process Form

To be used if you believe that the payment amount you received for a service is less than the amount indicated in our Terms and Conditions of Payment. Submit this form along with a copy of the claim being disputed and all supporting documentation.

Provider PFFS Appeal Form

To be used when submitting a provider appeal for medical necessity and/or benefits. Submit this form along with all additional, appropriate appeal forms and medical records.

Waiver of Liability Form

To be used when using the member’s appeal process. It promises you will hold the member harmless regardless of the outcome.

W-9 Form—Request for Taxpayer Identification Number and Certification

To be used to submit your tax identification number and certification either for the first time or anytime your tax information changes.

Pharmacy/Prescription Drug Forms

Injectable/Infusion Prescription Order Form

To be used for an injectable infusion prior authorization request.

Drug Evaluation Process

Drug Evaluation Review (DER) Form

To be used to determine coverage for medication prior authorizations, non-formulary medications and medications with utilization management rules.

Redetermination Form

To be used when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered or what we will pay for a prescription drug. In order to file an appeal, you must first go through the Drug Evaluation Review (DER) process.

IRE Reconsideration Form

If the decision of the prescription drug appeal (redetermination) is to continue the denial of coverage or payment, then the member or the member’s appointed representative has the right to file a request for reconsideration with Maximus, a company contracted by Medicare to review managed care organization denials. This is the form that should be used for that process.