Provider Forms

  • Browse a wide variety of our most frequently used forms. Can't find the form you need? Contact us.

    For additional member forms, view our specific plan pages:

    Individual plans

    Federal Employee Program (FEP) plans

  • When to submit an appeal When not to submit an appeal
    • Clinical edit disagreement – with the appeal, submit supporting documentation (such as CMS) showing correct billing
    • Medical necessity denials that are provider write-offs
    • If allowed amounts disagree with the contracted rate, multiple same-day reductions, denials for inclusive procedures, or OrthoNet denials
    • Claims denied for timely filing
    • Billing errors
    • Duplicate or eligibility denials
    • Corrected claims
    • Claims denied for needing medical records, incident questionnaires, or other additional processing info
    • Other coverage denials like COB, worker’s comp or subrogation

    Note: Carewise audit appeals should go directly to Carewise as noted in the letter sent to providers.

    Appeals

    Appeal submission with authorization - 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 providers submitting on a member’s behalf (section C).

    BlueCard appeal submission - For out-of-area BlueCard members appealing the home Blue plan.

    View our individual plans page for additional appeal forms.

    Policy reconsideration

    Policy reconsideration - Request reconsideration of a coding policy. 

    Processing or correcting claims

    Corrected claim cover sheet - Correct billing info, codes or modifiers, or add an EOP on a previously processed claim. For more details, see our corrected, replacement, voided, and secondary claims section.

    Support document cover sheet - Submit medical records or other required supporting documentation to process a 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.

    Billing

    Overpayment notification - Notify Premera of an overpayment your office received.

    Letter for refunds less than $25 - We don't send a letter requesting a refund for overpayments of less than $25 per claim. Use this form for your documentation purposes.

    Care management

    Admission notification and discharge notification

    Prior authorization and pre-approval

    Learn more about submitting prior authorization, including for DME.

    General prior authorization request

    Out-of-network exception request - Request in-network benefits for an out-of-network service.

    Durable medical equipment (DME)

    Infusion drugs

    Pharmacy

    Pharmacy pre-approval request

    Premera uses ProviderSource ™ to manage data for credentialing, recredentialing, and privileging. ProviderSource is free and requires:

    • An attestation date not older than 150 days.
    • Up-to-date attachments, including the federal Drug Enforcement Administration (DEA) certificate and malpractice insurance fact sheet.

    View our practitioner credentialing checklist or the Join Our Network page for more 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.

    IRS SS-4 confirmation letter - Include a copy of this letter to show your Employer Identification Number or EIN.

     

    Provider updates and facility credentialing

    Provider update - Email this form to Premera with new information or changes to your current practice or payment structure. The federal No Surprises Act requires health plans to verify all provider directory data every 90 day. It also requires all providers and facilities submit this information to in-network plans. Unverified providers may be removed from our directory.

    Organization/facility credentialing/recredentialing application - To join our provider network as a facility, complete this application and a W-9 form. Email us your completed documents. The credentialing process typically takes 30 days. Acceptance is based on your application information and network requirements. If your submitted application is accepted, you'll receive a contract to review and sign. Once you return your signed contract, you’ll receive a counter-signed contract and the effective date of your participation.