Submit with a CMS-1500

Enter your claims data on the CMS-1500 form. The forms shown on the linked page is known as the 02/12 verson, and Well Sense accepts this version as of 03/01/2014. The older version (08/05) will no longer be accepted as of 04/04/2014. 

You will need to include the following information so that we can process your claim:

  1. The 9-digit Well Sense Member ID (beginning with NH) in Box 1a, available on our member portal or by calling Provider Services at 877-957-1300.
  2. Your Tax ID in Box 25 AND either the individual practitioner NPI in Box 24J and/or the group NPI in Box 33a.

See detailed instructions for filling out this form.

Print and mail completed form via U.S. mail to:

Well Sense Health Plan
PO Box 55049
Boston, MA 02205-5049

Sending claims via certified mail does not expedite claims processing and may cause delays.