How to Complete and Submit the Wellmark Prior Authorization Form

To submit a Wellmark prior authorization form, download the single-page PDF from Wellmark’s provider forms page, complete every field, attach chart notes, and fax it to 888-836-0730 for medical services or 866-249-6155 for specialty drugs. One caveat before you start: the paper form is only for non-contracting or out-of-state providers. If you are contracted with Wellmark, the request must go through Jiva inside the Wellmark Provider Portal, and a paper submission will be returned.¹

Who Should Use the Paper Form

Wellmark runs two submission paths and enforces the split.

Non-contracting or out-of-state providers use the paper Prior Authorization Request form, submitted by fax.²
Contracting (in-network) providers submit medical requests through Jiva in the Provider Portal and drug requests through NovoLogix. Availity is not the authorization tool; Wellmark has confirmed Jiva and NovoLogix remain the required platforms.³

As of January 1, 2026, chiropractic therapy, physical therapy, and occupational therapy moved from the treatment plan process to prior authorization and are submitted through Jiva.¹

Confirm the Service Actually Needs Authorization

Before filling anything out, check Wellmark’s Medical Authorization Table. It lists CPT and HCPCS codes with a “Pre-service Review Required” column. A “Yes” means authorization is required. A code that doesn’t appear on the table at all means Wellmark has no medical policy for it and no pre-service review is needed.⁴

Durable medical equipment is handled the same way: listed on the table with “Yes” means pre-service review applies. The list changes, so check it rather than guessing.⁴

Patient and Service Fields on the Form

The form is a single page, and Wellmark returns it if any field is blank or if chart notes are missing. The first block covers who the patient is and what you’re asking for.⁵

Patient name, date of birth, phone, and address. Match the name exactly as it appears on the member’s insurance card.
Member/Patient ID number from the Wellmark card.
ICD-10 diagnosis codes supporting medical necessity.
CPT or HCPCS codes for the planned procedure or supply.
Service type checkbox: inpatient hospital, office surgery, DME, outpatient diagnostics, or outpatient surgery/ambulatory surgical center.
Date of admission or procedure.
Number of visits, units, or days.
Authorization date span you want the approval to cover.
Previous authorization number, if this continues or modifies an earlier approval.

One trap on this page: if you want the request reviewed as inpatient, specify inpatient admission with the appropriate code in the CPT field. Without that, Wellmark reviews the request as outpatient. For inpatient requests, also include a justification explaining why the admission can’t be handled on an outpatient basis.⁵

Provider and Facility Fields

Requesting provider and NPI (the physician ordering the service).
Treating provider and NPI (the physician who will perform the service, if different).
Admitting provider and NPI (inpatient requests only).
Servicing facility and NPI (hospital, surgical center, or other site of service).
Contact name, phone, and fax where Wellmark should send questions or the decision.

The form does not ask for a Tax Identification Number. NPIs are the identifying credentials throughout.⁵

Attach Chart Notes

Chart notes are required with every submission. Wellmark explicitly returns incomplete requests to the sender.⁵ Most denials start here rather than in the medical facts themselves: the clinical story on the page doesn’t line up tightly enough with the criteria the reviewer is applying.

Include the patient’s medical history, relevant physical exam findings, and a record of previously attempted treatments that did not resolve the condition. Wellmark’s medical directors evaluate the request against evidence-based clinical criteria, and documentation that maps directly to those criteria moves faster. Vague summaries get held for additional information, which resets the review clock.

Where to Fax the Form

Medical services: 888-836-0730
Specialty drugs: 866-249-6155

Wellmark faxes the approval or denial back to the number you listed in the contact section.² If you need help with utilization management questions, including medical precertification, continued stay, and prior authorization requirements, non-contracted providers can call 800-552-3993 and select option 2.⁶

How Long the Decision Takes

Wellmark responds within 10 calendar days for normal-priority medical service requests.⁴ That is tighter than the ERISA ceiling for health plans, which allows up to 15 days for non-urgent pre-service claims and 72 hours for urgent care claims.⁷

The form has a field for justifying an expedited request. Leave it blank and the request runs at standard priority; there is no automatic escalation based on service type alone.⁵

How Long an Approval Stays Valid

An approved authorization is good for a defined period, provided the patient’s benefit plan does not change between the approval date and the date of service.² Federal Employee Program (FEP) prior approvals are typically valid for 90 days.⁸ For other plans, the validity period varies by service type and is noted on the approval notice itself.

If the service date shifts but still falls within the authorization window, you don’t need to resubmit. A change in the patient’s benefit plan does require a new request, no matter how much time remains on the original.⁹

If the Request Is Denied

The denial notice will state the specific reason. Wellmark directs providers to its member and provider inquiry and appeals process through the secure Provider Portal.⁴ The usual sequence:

Peer-to-peer review. The requesting physician can often speak directly with the plan’s medical director about the clinical rationale, and that conversation sometimes reverses a denial before any formal appeal. It must happen before an appeal starts; once the appeal process is open, a peer-to-peer discussion generally cannot change the outcome.
Internal appeal. A formal request asking Wellmark to reconsider, usually paired with additional clinical documentation that addresses the stated reason for denial.
External review. If the internal appeal is also denied, federal law gives you the right to an independent external review. File a written request within four months of the final internal denial. An independent review organization staffed by board-certified specialists reviews the case. Standard external reviews must be decided within 45 days; expedited reviews for urgent situations within 72 hours. The cost to the patient is either nothing or no more than $25, depending on the review process used.¹⁰

External review is available for any denial involving medical judgment, experimental treatment determinations, or coverage cancellation. The patient can appoint a representative, often the treating physician, to file the external review request.¹⁰

Step Therapy for Prescription Drugs

Some drugs on Wellmark’s formulary carry a step therapy designation, marked “(ST).” The patient must try one or more lower-cost formulary drugs before Wellmark covers the prescribed medication, which comes up most often with specialty and high-cost drugs.¹¹

If the step-one drug is not appropriate because of contraindications, a prior adverse reaction, or documented treatment failure, the prescriber can call the pharmacy help desk (number on the back of the member’s Wellmark ID card) to request an exception. The physician provides clinical evidence of why the preferred drug is unsuitable and why the requested medication is necessary.¹¹

1
Wellmark Blue Cross and Blue Shield. Forms for Providers
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Wellmark Blue Cross and Blue Shield. Types of Medical and Drug Authorizations
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Wellmark Blue Cross and Blue Shield. Frequently Asked Questions for Providers – Availity
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Wellmark Blue Cross and Blue Shield. Medical and Pharmacy Authorization Details
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Wellmark Blue Cross and Blue Shield. Prior Authorization Request Form (PDF)
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Wellmark Blue Cross and Blue Shield. Contact Information for Providers
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U.S. Department of Labor. Filing a Claim for Your Health Benefits
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Wellmark Blue Cross and Blue Shield. FEP Medical Authorizations
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Wellmark Blue Cross and Blue Shield. Authorizations and Approvals
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HealthCare.gov. External Review
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Wellmark Blue Cross and Blue Shield. 2026 Prior Authorization Step Therapy (PDF)