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)
- Predetermination Request Form (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)
- Waiver of Liability Statement (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.
Member ID Card Samples
- H5439-010 Wellcare Patriot No Premium Open (PPO MA-Only) - front (PNG)
- H5439-010 Wellcare Patriot No Premium Open (PPO MA-Only) - back (PNG)
- H5439-011 Wellcare Premium Ultra Open (PPO) - front (PNG)
- H5439-011 Wellcare Premium Ultra Open (PPO) - back (PNG)
- H5439-015 Wellcare Giveback Open (PPO) - front (PNG)
- H5439-015 Wellcare Giveback Open (PPO) - back (PNG)
- H5439-017 Wellcare No Premium Open (PPO) - front (PNG)
- H5439-017 Wellcare No Premium Open (PPO) - back (PNG)
- H5439-019 Wellcare Low Premium Open (PPO) - front (PNG)
- H5439-019 Wellcare Low Premium Open (PPO) - back (PNG)
- H6815-037 Wellcare Assist (HMO) - front (PNG)
- H6815-037 Wellcare Assist (HMO) - back (PNG)
- H6815-038 Wellcare No Premium (HMO) - front (PNG)
- H6815-038 Wellcare No Premium (HMO) - back (PNG)
- H6815-039 Wellcare No Premium (HMO) - front (PNG)
- H6815-039 Wellcare No Premium (HMO) - back (PNG)
