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  • Wellcare Ohio Provider Appeals And Billing Disputes Ohio Form

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Nt Information Request Date: Has the service been provided yet? Yes No Expedited Request? Yes No (See reverse side for definition of Exp. Request) Patient Information Name: Name: Address: ID Number: City: Date of Birth: Telephone:.

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Claim payment appeals must be submitted in writing to WellCare within 24 months of the date on the EOP. All supporting documentation must be submitted along with the claim payment appeal request.

You or your provider must call or fax us to ask for a Expedited Appeal. Call us at 1-877-389-9457 (TTY 711 or 1-877-247-6272). Or fax it to 1-866-201-0657. If you file your Expedited Appeal by phone, written notice is not needed.

Attn: Appeals Department, P.O. Box 31368 Tampa, FL 33631-3368. This form is to be used when you want to appeal a claim or authorization denial. Fill out the form completely and keep a copy for your records. Send this form with all pertinent medical documentation to support the request to WellCare Health Plans, Inc.

You have 60 calendar days from the date of the Initial Benefit Determination notice to file an appeal. You can call Customer Service at 1-800-288-5441 (TTY 711) for help filing a Plan Appeal.

The following Wellcare plans offer Medicare Advantage Prescription Drug plan coverage to Kentucky residents. Medicare Advantage plus Prescription Drug plans are an alternative way to get your Original Medicare.

Expediting Clinical Appeals Call us at 1-855-852-7005 to expedite a clinical appeal.

Providers must use the WellCare payer id 14163 if choosing to use Connect Center free DDE or batch upload services. WellCare encourages electronic (EDI) claim submissions.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232