To request a prior authorization or for questions about benefits, eligibility or claims status, contact Customer Service at (800) 394-5566 or TTY  711. To submit a request to join our network, complete the Provider Participation Request Form and send it to

Benefit Plan Exclusion Lists

Gundersen Senior Preferred

Elite & Value Exclusion List

ProHealth Senior Preferred

Elite Exclusion List

UW Health Senior Preferred

Elite Exclusion List

Value Exclusion List

Other Forms

Provider Participation Request Form

Non-Contracted Provider Notification of Appeal Process

Non-Contracted Provider Waiver of Liability

Claim Reopening Request Form

Claim Adjustment Form

Coding Denial Appeal Form
(used when there is a request for review of coding related denial with an explanation of why provider feels it is coded correctly or when there is a request of Appeal of Coding denial with explanation & supporting documentation. A claim should not accompany this form)


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This web page was updated on September 12, 2019.