Provider forms and documents
View and download provider materials
Browse commonly requested forms and documents.
Provider reference / notification requirements
The Provider Reference Sheet lists member copay amounts and the notification requirements for services and procedures that require preapproval review.
HCAS Provider Enrollment Form
Submit the Healthcare Administrative Solutions (HCAS) Provider Enrollment Form to enroll as a Wellpoint contracted provider. If you are enrolling a group, complete a separate form for each provider who is enrolling
Delegated Providers can utilize our standard provider roster template to add new providers. Fully completed rosters can be emailed to WellpointProviderRelations@wellpoint.com for processing. This new template will expediate the loading of your providers and to be most effective, the following standards have been put in place. Following these standards for submissions will allow for seamless processing:
- Providers should send via rosters one-to-two times per month versus sending individual changes.
- Preference is one roster update per month.
- Add additional rows for provider with multiple addresses.
- Please do not email individual provider submissions to our provider mailbox.
- Do not password protect submitted roster/Excel file. Instead, send SECURE
- Updates to provider data should not include changes that are effective dated greater than 12 months in advance.
- Individual or Group terminations should be submitted in a separate tab..
Provider Information Change Form
If you are currently a Wellpoint contracted provider, use the Provider Information Change Form to notify Wellpoint of changes to your practice such as new providers in your group.
Wellpoint member ID cards
Wellpoint member ID cards show copay amounts and other plan information.
Member and Provider Urgent Appeals
This notification is to encourage and remind members and providers that the preferred method for Urgent Appeals is by phone or fax as this is the fastest method for your urgent appeal to be handled.
What if my situation is urgent?
You’ll need to ask for an expedited appeal. Your situation is urgent if:
Your life, health or ability to regain maximum function is in jeopardy (danger), or
In your doctor’s opinion, your pain can’t be controlled while you wait for a standard appeal review to be finished.
An expedited appeal must be filed before services are provided or while services are ongoing. This means you can’t ask for an expedited appeal after services have already been provided.
How do I file an expedited appeal?
You can mail your request, but it’s best if you call Member Services at the phone number on your ID card. Or, fax your request to 866-273-3692 so we can handle it fast.
How long does an expedited appeal review take?
We’ll do a review and give you a decision within 72 hours of receiving the request. We’ll let you know the decision by phone. We’ll also send it to you in writing.