New Provider Appeal Form

  • January 4, 2018

    Premera has a new provider appeal form on in our forms section. This new form has an improved, fillable format, and will save you time as you submit appeals. To avoid confusion, delete any previous versions of the forms.

    Here's what we're requesting on the form:

    Front Side of Form: Details about the provider and member. It also includes our member appeal authorization section for non-contracted providers only. If you're contracted with Premera, you can skip the authorization section (Section C) and leave it blank-you're already authorized to appeal.

    Reverse Side of Form: Details about why you're submitting an appeal or complaint. Attach any supporting documentation when submitting.

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