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
Please visit our Behavioral Health Services Transition webpage for information about Behavioral Health Services administration effective January 1, 2024.
Resources
Wellcare By Health Net
Plan Materials and Forms
View Summary of Benefits, Evidence of Coverage and more.