Wellcare Providers
Thank you for being a trusted partner in care. We’re dedicated to working alongside you to ensure your patients receive the highest quality care.
On our site, you’ll find a range of helpful resources including key documents and forms, clinical guidelines, news and other updates.
Join Our Provider Network
Not a Wellcare Provider? Complete our “Join Our Network” form to begin the contracting process.
Provider Engagement
Availity Essentials Portal
Provider Notices and Bulletins
Provider Portal
Pre-Authorization
Medical Necessity Criteria
Wellcare wants to ensure that claims are handled as efficiently as possible. Providers can help facilitate timely claim payment by having an understanding of our processes and requirements.
Start Submitting Electronic Claims
- Register for Availity (for support call 1-800-AVAILITY (282-4548), or
- Contact Provider Engagement Account Managers by email at providerrelations@iowatotalcare.com
Timely Claims Submission
- Clean Claims (initial, corrected and voided) must be submitted within 180 calendar days from the date of service or from the date of discharge (for inpatient services).
- Claims Payment Disputes must be submitted in writing within 90 calendar days of the date of denial of the Explanation of Payment (EOP).
Reimbursement Policies
From time to time, Wellcare Health Plans reviews its reimbursement policies to maintain close alignment with industry standards and coding updates released by health care industry sources like the Centers for Medicare and Medicaid Services (CMS), and nationally recognized health and medical societies.
Wellcare has created several educational resources for providers.
New Provider Orientation
Fraud, Waste and Abuse Training
The Centers for Medicare & Medicaid Services (CMS) requires all delegated and contractual Medicare Part C and Part D providers to complete Fraud, Waste and Abuse (FWA) training. Combatting Fraud, Waste and Abuse (FWA) Training is available online for Wellcare providers.
FWA Training must be completed within 90-day of contract effective date and annually thereafter.
SNP Model of Care Training Materials
Health plans are required to provide their Special Need Plans (SNP) provider network with information about their basic model of care. Wellcare has created self-study materials that online basic requirements and frequently asked questions.
Model of Care training must be complete within 30-days of contract effective date and annually thereafter.
The Quality Improvement Program includes initiatives to ensure that members are receiving age-appropriate preventive health screenings and interventions to optimize health.
The information on this page provides useful information and tools for managing patient care based on industry-standard clinical practice guidelines.
Quality Quality Practice Advisors (QPA)
Our local Quality Practice Advisors (QPA) focus on the quality and safety of clinical care and services provided to members. They partner with providers to help identify opportunities to bring quality-related educational initiatives to life, address quality concerns, review clinical quality reports and scorecards and close care gaps. We’re here for you. Contact our Quality Practice Advisors at quality@iowatotalcare.com.
New: HEDIS® Measurement Year 2025 Toolkit
HEDIS Measurement Year 2024 Toolkit
Quality Measures
- Medicare Advantage Annual Preventive Care (PDF)
- Controlling Blood Pressure (PDF)
- Colorectal Cancer Screening (COL-E) (PDF)
- Diabetes Care (GSD) (PDF)
- Medication Adherence Provider Flyer (PDF)
- Osteoporosis in Women Who Had a Fracture (OMW) (PDF)
- Social Determinants of Health (SDOH) (PDF)
- Statin Use Measures (PDF)
- Transitions of Care (TRC) (PDF)
CAHPS and HOS Resources
Get paid fast! Wellcare offers electronic funds transfer (EFT) and electronic remittance advice (ERA) services at no charge in partnership with PaySpan Health, our automated clearinghouse. Register for PaySpan
Disputes, Reconsiderations and Grievances
- Appointment of Representative (PDF)
- Participating Provider Payment Dispute Form (PDF)
- Non-Par Provider Payment Dispute Form (PDF)
- Participating Provider Reconsideration Request (PDF)
- Non Par Provider Appeal Form (PDF)
- Provider Waiver of Liability (WOL) (PDF)
Claim Forms
- CMS 1500 Submission Sample (PDF)
- NDC Reporting Guidelines (PDF)
- Refund Check Information Sheet (PDF)
- Refund Referral Grid (PDF)
- UB-04 Submission Sample (PDF)
Medical Records
Pharmacy Forms
- Alternative Covered Drugs (PDF)
- Hepatitis C Treatment Prior Authorization Request (PDF)
- Hospice Information for Medicare Part D Plans (PDF)
- 2026 Medicare Part B Step Therapy Criteria Policy (PDF)
- Medical Drug Authorization Request (PDF)
- Request for Medicare Prescription Drug Coverage Determination - Medicare (PDF)
- Redetermination Request Form for Part D Denials (PDF)
Other Provider Forms
Special Supplemental Benefits for the Chronically Ill (SSBCI) can be offered to Medicare Advantage (MA) members who have one or more complex chronic conditions, are at high risk for hospitalization or adverse health outcomes and require intensive care coordination. SSBCI aims to improve overall health outcomes for the chronically ill population by addressing social needs beyond traditional medical care such as food, housing, transportation, and gaps in care. The program is designed to support individuals by offering additional services beyond standard Medicare coverage.
Members must qualify for SSBCI benefits
Members must meet all three criteria to qualify:
- The member must require intensive care management.
- The member must have a history of frequent outpatient services or specialty care and/or, evidence of poor disease control or medication adherence and/or, social or behavioral factors impacting health outcomes.
- The member must be at high risk for unplanned hospitalization.
- The member must have a history of frequent hospitalizations or ED visits related to the chronic condition.
- The member must have a documented and active diagnosis for a qualifying chronic condition.
- The chronic condition must be life threatening or significantly limit the overall health or function of the member.
How to Determine Eligibility
Auto Eligibility Process: We utilize internal and claims data in our internal algorithm to identify members that meet the three criteria. This automatic process refreshes weekly, and links member data across time and health plans, enabling a comprehensive view of historical claims. This process includes all members enrolled in an SSBCI-eligible plan.
Manual Eligibility Process: We may not have claims data or medical records for new members early in the year. These members can go through the manual process to have a provider attest to their eligibility.
To begin the SSBCI manual eligibility process, members must schedule an in-person office visit or contact their healthcare provider to request the attestation be completed. If an office visit is required to complete the attestation, the provider will evaluate the member’s health status during the visit and determine if they meet SSBCI criteria.
Provider Instructions for SSBCI Attestation
Providers should follow these steps to complete the attestation:
- Visit ssbci.rrd.com.
- Review the eligibility criteria outlined on the site (see criteria above) and evaluate the member accordingly.
- Submit an attestation through the website confirming the member meets SSBCI eligibility requirements.
- Submit a claim from the office visit that includes the appropriate diagnosis codes indicating the member has one or more What Happens Next?qualifying chronic conditions listed on ssbci.rrd.com.
What Happens Next?
Once the attestation is received:
- The member will receive an approval or denial letter within 10 business days.
- If approved, the letter will include details about the specific SSBCI benefits available and instructions on how to access them.