Manuals, Forms and Resources
Manuals
Wellcare By Health Net
Forms
Wellcare By Health Net
- Appointment of Representative Form - Medicare - English (PDF)
- Appointment of Representative Form - Medicare - Spanish (PDF)
- Outpatient Case Management Referral Form (PDF)
- Certification for Contracts, Grants, Loans, and Cooperative Agreements Form (PDF)
- Decision Power Referral Fax (PDF)
- Fraud, Waste and Abuse and General Compliance Annual Training Attestation Form (PDF)
- Interpreter Service Quick Reference Card (PDF)
- Lobbying Activities Form and Disclosure Form Instructions (PDF)
- Medicare Inpatient Authorization Form (PDF)
- Medicare Outpatient Authorization Form (PDF)
- Offshore Subcontracting Attestation: Participating Provider (PDF)
- Potential Quality Issue Referral Form (PDF)
- Prior Authorization/Medication Exception Request Fax Form (PDF)
- Provider Claim Dispute Resolution Request (PDF)
- Remittance Advice Sample - Washington (PDF)
- Reopen Request Form (PDF)
Commercial
- Provider Claim Dispute Resolution Request (PDF)
- Commercial Inpatient Prior Authorization Request Form (PDF)
- Commercial Outpatient Prior Authorization Request Form (PDF)
- Request for Confidential Communication Form (PDF)
- Telemedicine Provider Attestation (PDF)
Behavioral Health
- Diagnostic Evaluation Assessment Form (PDF)
- Neuropsych Testing Request Form (PDF)
- Psych Testing Request Form (PDF)
Resources
Wellcare By Health Net
Plan Materials and Forms
View Summary of Benefits, Evidence of Coverage and more.
