Browse a wide variety of
our most frequently used forms. Can't find the form you need? Contact provider customer service for HMO at 844-PBC-HMO1 (844-722-4661) or email email@example.com.
Provider 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
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.
cover sheet - Submit medical records or other required supporting documentation to process a claim.
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.
Balance billing protection act dispute – Providers or facilities not contracted with Premera can submit a balance billing dispute request. The
form must be received by Premera within 30 days from receipt of the original payment notification. Find out more about the
Balance Billing Protection Act.
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.
Visit our Join Our Network page for credentialing information.
Email a completed provider update 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 days. It also requires all providers and facilities submit this information to in-network plans. Unverified providers may be removed from our directory.
Sign in to Availity to submit prior authorizations and check codes.
Admission notification and discharge
Continuity of care for members
Transition of care for members
General prior authorization request
Durable medical equipment (DME) request
Out-of-network exception request - Request in-network benefits for an out-of-network service.
Upcoming policies for review
Total joint replacement exception request - Specific to Washington small group members requesting a provider or facility that isn't a Premera-Designated Center of Excellence for total knee or hip replacement.
Pharmacy services prior authorization request form
Referral provider fax form
Learn about Premera HMO plan contracts, features and tools.