For your convenience, we’ve categorized our most frequently used forms below. If you can’t find the form you need or require further assistance, please contact us.
Appeal Authorization Form - When submitting an appeal on behalf of a member, include this form signed by the member authorizing release of healthcare information and records.
Appeals Submission Form - For Contracted Providers - Use this form to resolve billing issues that directly impact payment or a write-off amount.
Corrected Claim Cover Sheet - Use this form to correct billing information on a previously processed claim.
Incident Questionnaire - Use this form when a patient has sustained an injury or was involved in an accident.
Other Coverage Questionnaire Enrollment - Use this form to provide information about other healthcare coverage a patient may have.
Overpayment Notification Form - Use this form to notify Premera of an overpayment your office received.
Request to Enable Real-Time Claims - Use this form to add real-time claims submission capability to the estimate tool.
Standard Provider Letter for Refunds Less Than $25 - We do not send a letter requesting a refund for overpayments of less than $25 per claim. Use this form for your documentation purposes.
Support Document Cover Sheet - Use this form to submit supporting documentation that is required to process a claim.
Use the following forms to submit a pre-service review request if a service is medically necessary
*This form is used to submit all types of requests for medical necessity.
FEP Prior Approval Request/Response
FEP Prior Approval Request/Response - Hospice - Use this form for FEP patients to submit required prior approval request for certain* procedures.
ProviderSource™ - ProviderSource is 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 Application - Use this form to request to join Premera's professional provider network.
Practitioner Credentialing Checklist - Use this checklist to ensure Premera receives all the required credentialing documents needed to become a participating provider.
Behavioral Health Specialty Addendum - Use this form to provide Premera with a provider's behavioral health primary areas of clinical expertise.
Dental Provider Credentialing Application - Use this form to join Premera's dental provider network.
Organization/Facility Credentialing/Recredentialing Application - Use this form to request to join Premera's facility provider network.
Internal Revenue Service W-9 - Use this form to provide Premera with your current Taxpayer Identification Number (TIN) information.
Confidential Exchange of Information Form - Sample form template for the exchange of information between medical and behavioral health providers.
Contracted Provider Information Changes - Premera contracted providers can email this form to Premera with new information or changes to their current practice or payment structure.
Dental Insurance Verification - Use this form as a template for documenting dental benefits when calling customer service for a dental benefit quote.
Healthcare Provider Biometric Screening Form - This form is for Premera members in the Metallic Wellness Program who are requesting a wellness biometric screening.
Non-Contracted Provider Information Changes - This form is for non-contracted providers to notify Premera of any new information or changes to their current practice.
Policy Reconsideration - This form should be used to request reconsideration of a coding policy.
Practitioner Data Sheet - Provider specialties (audiologists, etc.) that don’t require credentialing can use this form to request to join Premera’s professional provider network.
Serious Adverse Event Form - Facilities can use this form to report Serious Adverse Events.