Forms and Documents

Form

Purpose

Fax or Send to:

Administrative

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
Claims Department
PO Box 55049
Boston, MA 02205

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   

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)
NHPreAuth@wellsense.org

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

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

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 

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

 Quick Reference Guide  Download and print this guide for easy access to useful contact information.

Prior Authorization Information

Prior Authorization Matrix Identifies medical services requiring authorization or notification

To Check Covered Benefits

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

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.
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

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