Resources
Forms and Documents
Form |
Purpose |
Fax or Send to: |
Administrative |
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Acknowledgement of Sterilization as a Result of a Hysterectomy | Submit this form prior to performing a hysterectomy to confirm the patient's understanding of sterilization. | 603-218-6725 |
Care Management Referral Form | Use this form to refer members to our Care Management program | 866-409-5657 |
Certification for the Decision to Terminate Pregnancy | Complete this form for coverage of an abortion. |
Well Sense Health Plan |
Consent for Sterilization | Use this form to confirm a patient's consent for sterilization. | 603-218-6725 |
Notification of Birth Form | To ensure continuity of care and enrollment of a new baby whose mother is already a Plan member | |
Waiver of Liability for WellSense Medicare Advantage Non-participating Providers | Non-participating Medicare Advantage providers may use this form to waive liability. | |
Prior Authorization |
||
Standardized Prior Authorization Request Form with Instructions |
General form used for most medical requests; be sure to attach supporting clinical information |
603-218-6634 (initial requests) |
Pharmacy Prior Authorization Forms |
Check to see if prior authorization is required, then complete the form next to the drug name | Consult the fax number on the form |
Provider Activation, and PCP/Provider Changes |
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Change Form and Provider Termination Notification Form | For providers changing their information or terminating | 866-779-5948 or NHProvider.Enrollment@wellsense.org |
Facility/ Ancillary Provider Data Form | For providers to ensure accurate record set-up, please complete one form per NPI. | 866-779-5948 or NHProvider.Enrollment@wellsense.org |
HCAS Enrollment Form | For providers interesting in enrolling with us | 866-779-5948 or NHProvider.Enrollment@wellsense.org |
Locum Tenens Credentialing Form and Attestation | For locum tenens providers |
866-779-5948 or NHProvider.Enrollment@wellsense.org |
Member PCP Transfer Request Form | For a provider to complete should they want to modify their patient panel | 617-897-0838 or Enrollment.Mailbox@BMCHP-wellsense.org |
NH Medicaid Provider Enrollment Application | First step to becoming a Well Sense Health Plan Provider |
DHHS vendor, ACS Provider Enrollment 603-223-4774 |
Non-Participating Provider Activation Form |
For non-participating providers who will be delivering a one-time service to a member |
866-779-5948 or NHProvider.Enrollment@wellsense.org |
Primary Care Provider Selection Form | For members to elect their PCP at their doctor's office | 866-335-9317 or Enrollment.mailbox@wellsense.org |
Provider Data Form | For providers interested in enrolling with us | 866-779-5948 or NHProvider.Enrollment@wellsense.org |
Claims |
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Claim Review Form | To request a claim review | Well Sense Health Plan PO Box 55049 Boston, MA 02205 |
Credit Balance Refund Data Sheet |
To report overpayments | 617-897-0811 |
Electronic Funds Transfer Request |
Submit this form to request payment by electronic funds transfer. View our EFT setup guide for instructions and FAQs. |
NHProviderInfo@bmchp-wellsense.org |
Electronic Remittance Advice Authorization Form | Enroll, change enrollment, or cancel enrollment in Electronic Remittance Advice (ERA). View our ERA setup guide for instructions and FAQs. | era.requests@wellsense.org |
Paper Remittance Request Form |
Use this form to request paper remittance advices if you are unable to receive electronic remittance advices. |
603-263-3055 |
Membership |
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Member Authorized Representative Form | For members to name an authorized representative for an appeal. View in Spanish. | 617-897-0884 |
Notification of Birth Form | To ensure continuity of care and enrollment of a new baby whose mother is already a Plan member | 866-335-9317 |
Document |
Purpose |
|
---|---|---|
General Contact Information |
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Quick Reference Guide | Download and print this guide for easy access to useful contact information. | |
Prior Authorization Information |
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Prior Authorization Matrix | Identifies medical services requiring authorization or notification | |
To Check Covered Benefits |
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Covered Services List | Covered Services for Well Sense Health Plan members | |
COB Quick Reference Guide | Coordination of Benefits Quick Reference Guide for Well Sense Health Plan | |
Appeals Information |
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Contract Rate, Payment Policy or Clinical Policy Appeal | An appeal due to a contract rate, payment policy, or clinical policy dispute | |
Duplicate Denial Appeal | A request for review of a claim previously processed and denied as a duplicate to another claim | |
Filing Limit Appeal | An administrative appeal due to a claim denial for filing limit violations | |
Prior Authorization Appeals | An administrative appeal due to a claim denial due to lack of prior authorizations for services or for exceeding authorization limits. |
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Provider Appeals Quick Reference Guide | Assist you in correctly submitting claims appeals | |
Request for Additional Information Appeal | Submit in response to a claim originally denied for additional information | |
Pharmacy Program Information |
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Mandatory Generic Substitution Program | Well Sense Health Plan will authorize coverage of prescriptions where the prescriber has written "No Substitution" when appropriate criteria are met | |
New-to-Market Medication Program | Criteria for prior authorization coverage of new-to-market medications or new indications | |
Over the Counter Formulary | Lists the accepted generic versions of approved over-the-counter drugs | |
Quantity Limitation Guide | Dose and strength recommendations for drugs | |
Specialty Drug List | List of special pharmacies, drugs, categories, and codes | |
Prescription Drug Monitoring Program | Helps to identify member at risk of inappropriate drug use |
603-263-3055 |
Electronic Funds Transfer Authorization |