What to know about Wellpoint member claims

A health insurance claim is when you ask your insurance company to help pay for a doctor's visit or medical treatment covered by your health plan. A doctor sends a bill to your insurance after your visit. If you paid the full bill at your doctor's visit, you can ask the insurance company to pay you back. This is called sending a claim. Here is an easy guide on how to send a claim and what happens when Wellpoint receives it.

How to submit a Wellpoint claim

 

If you go to a doctor, pharmacy, or medical location that is part of your insurance plan, they will usually send a bill to Wellpoint for you. But if the doctor is not part of your plan, also known as out-of-network, you might have to pay at the time of your visit.

 

For some plans, if you paid for doctor visits, medicine, glasses, or other medical expenses, you send a claim to ask Wellpoint to pay you back. Wellpoint will look at your claim and decide how much you are owed. 

 

Submit a Wellpoint claim online

 

The easiest way to send a claim to Wellpoint is online. You will need a detailed bill from your doctor, called a “superbill.” A simple credit card receipt is not enough. Be sure to ask your doctor for a superbill, which should clearly say what you paid for.

 

If you paid in cash for medicine, you'll need to send a detailed receipt from the pharmacy. This receipt should include the name of the medicine, how much you take, the doctor who prescribed it, and the cost. If you bought glasses or other health items, the receipt should show the cost of every part, like the frames and lenses. Keep these receipts for your claim.

 

To send your claim online, follow these steps:
 

  1. Log in to your member portal. If you don’t have an account, you can make one here.
  2. Click on “Claims and Payments" in the navigation at the top of the page and then “Member Submitted Claims Center”.
  3. Click the “Submit a Claim” button.
  4. Fill out the form and upload a picture of your bill or receipt.
  5. Click “Submit.”

 

Other ways to submit a Wellpoint claim

 

Online is the fastest way. If you can’t do it online, you can manually submit your claim. Follow these steps:

 

  1. Log into your Wellpoint member portal.
  2. Click on “Support” in the navigation at the top of the page and then “Forms”.
  3. Choose the forms you need.
  4. Print the form and fill it out.
  5. Attach your bill or receipt.
  6. Send the form to Wellpoint.


The Wellpoint claims mailing address is:

Wellpoint, Inc.

PO Box 105187

Atlanta, GA 30348-5187

 

Online claims are processed faster than manually submitted claims. Wellpoint suggests submitting claims online to make sure we receive them quickly. If you need assistance, please call the member services phone number found on the back of your insurance card for support.

How Wellpoint claims processing works

 

If your doctor takes your insurance, they will usually send a bill to Wellpoint after your visit.

 

If your doctor doesn't work with your insurance or can't send the bill, you can send a claim to Wellpoint. Once Wellpoint gets your claim, we will check it. We will make sure everything is correct and your plan covers the care you received. Sometimes, Wellpoint may pay the full cost. But other times we might pay only part of it, and you'll need to pay the rest.

 

How much you'll have to pay depends on a few things. These include your deductible, which is a certain amount you must pay before Wellpoint starts helping cover costs. Another is your out-of-pocket maximum, which is the amount of money you must spend in a year before Wellpoint covers the rest. Lastly is a copay, which is a small set amount you pay every time you go to the doctor.

What happens after your claim is processed

 

After your Wellpoint claim is checked, you will get an Explanation of Benefits (EOB). The EOB shows what Wellpoint paid and what you may owe. You can log in to your member account or the SydneySM Health app to see your claim status and EOB.

 

 

If Wellpoint is paying you back, you will get a direct deposit or paper check, depending on what you choose. If you owe your doctor money, their office will send you a bill. You should also contact them to arrange payment.

Contact us if you need assistance

 

If you need help while trying to submit a claim to Wellpoint, don’t worry. You can contact Wellpoint for assistance. Please call the member services phone number found on the back of your insurance card for help. Representatives are available Monday through Friday from 8 a.m. to 8 p.m. Eastern time. You can also live chat with a representative from member services in the Sydney Health mobile app.