Here you'll find our most frequently used forms. If you can't find the form you need, please contact us.
Appeal submission form with authorization - for contracted providers - Resolve billing issues that directly impact payment or a write-off amount. Note the different fax numbers for clinical vs. general appeals. Member authorization is embedded in the form for non-contracted providers. See section C.
Corrected claim cover sheet - Correct billing information on a previously processed claim.
Incident questionnaire - Use when a patient has sustained an injury or was involved in an accident.
Other coverage questionnaire enrollment - Provide information about a patient's other healthcare coverage.
Overpayment notification form - Notify Premera of an overpayment.
Request to enable real-time claims - Add real-time claims submission capability to the estimate tool.
Standard provider letter for refunds less than $25 - We don't send a letter requesting a refund for overpayments of less than $25 per claim. You can use this form for your documentation purposes.
Supporting documentation cover sheet - Submit supporting documentation required to process a claim.
Forms to submit a pre-service review request if a service is medically necessary.
General prior authorization request
Out-of-network exception request - For out-of-network providers to request in-network benefits applied to their service.
Durable medical equipment (DME)
FEP prior approval request/response
FEP prior approval request/response - hospice - Use for FEP patients to submit a required prior approval request for certain procedures.
Admission and discharge notification request
ProviderSource ™ - A free service to help healthcare providers manage data used for credentialing, recredentialing, and privileging. Providers can use ProviderSource or a paper application. If using ProviderSource for recredentialing, the attestation date must not be older than 180 days, and all attachments, including the Federal Drug Enforcement (DEA) certificate and malpractice insurance fact sheet, must be kept current.
Practitioner credentialing checklist - Use this checklist to ensure Premera receives all the required credentialing documents needed to become a participating provider.
Practitioner application - Request to join our professional provider network.
Practitioner credentialing/recredentialing addendum - Provide us with the your medical record retrieval and practice information.
Behavioral health specialty addendum - Provide us with your behavioral health primary areas of clinical expertise.
Dental provider credentialing application - Request to join our dental provider network.
W-9 - Provide us with your current taxpayer identification number (TIN).
Organization/facility credentialing/recredentialing application - Request to join our facility provider network.
Confidential exchange of information form - Sample form template for the exchange of information between medical and behavioral health providers.
Provider update form - Email this form to Premera with new information or changes to your current practice or payment structure.
Dental insurance verification - Template for documenting dental benefits when calling customer service for a dental benefit quote.
Healthcare provider biometric screening form - Use for Premera members in the metallic wellness program who are requesting a wellness biometric screening.
Policy reconsideration - Request reconsideration of a coding policy.
Practitioner data sheet - Provider specialties that don't require credentialing can use this form to request to join our professional provider network.
Serious adverse event form - Facilities can use this form to report serious adverse events.