How do I submit a professional claim?

Electronic claims submissions provide real-time status updates, allow you to include authorizations and attach additional documentation as necessary as well as pre-populating member and provider information. To begin a Professional Claim Submission select a member and the member information will be pre-populated or manually enter the information in a blank form. Complete the required fields. Attach up to a maximum of 10 documents. The system will perform field level validation when you submit the claim.

How do I submit an institutional claim?

Electronic claims submissions provide real-time status updates, allow you to include authorizations and attach additional documentation as necessary as well as pre-populating member and provider information. To begin an Institutional Claim Submission select a member and the member information will be pre-populated or manually enter the information in a blank form. Complete the required fields. Attach up to a maximum of 10 documents. The system will perform field level validation when you submit the claim. For your convenience, the electronic version of the Institutional Claim was designed to have the same look as the paper claim form.

How do I check claim status?

View claim status at any phase during the process, including Denied with denial reason.  To check claims status, begin by searching for one or multiple claims. You can lookup claims using either the WellCare Control Number (WCN), Claim Number, Medicaid ID, Medicare ID, Member ID or Member Name and Date of Birth.

Can i view full claim details?

Begin by searching for a claim or multiple claims on the Search Claims webpage. To view full claim details, click on the Select Action drop down then select View Details.

How do I correct a claim?

Correct a claim by performing a search for one or multiple claims. To correct the claim click on the Select Action drop down then select Correct Claim. Fields from the original claim are pre-populated and editable except for the member and provider IDs.

How do I appeal a denied authorization?

To appeal an authorization in Denied status, search for the authorization using one of these criteria: Member/Subscriber ID, Provider ID, Patient Name and Date of Birth, Medicare ID or Medicaid ID. Search results will display based on date of service. Select Authorization Appeal from the drop down. Fields will be pre-populated from the original authorization request. Attach supporting documentation as necessary. Note:  For the Medicaid lines of business, an appeal cannot be submitted unless the member consent checkbox is selected.

How do I appeal a claim?

To appeal a denied claim use Search Claims search for a claim that has been denied. Once you locate the claim, click on the Select Action drop down then select Appeal Claim and fill in the fields. Attach documents that support your appeal request. If you need a response within 72 hours click the checkbox marked Expedited/Urgent.

How do I dispute a claim?

You can dispute a claim with a status of fullypaid. Use the claims search option to find the claim. From the Select Action drop down, choose Dispute Claim. A form will open with the fields pre-populated from the original claim. Choose the paid line items you want to dispute. When you submit the dispute, the system will validate the fields for errors prior to submission.

Can I save a draft of my claim?

You can save a partially completed claim and retrieve it for later use. The draft claim must contain a provider ID, member ID, one manually-entered field. The system will validate that these fields are populated and save the draft. Claims drafts are saved until you retrieve them for further action.