Provider Forms - Premera HMO Core Plus Plan

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 (section C). 

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

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.

Care management

Admission notification and discharge notification

Continuity of care for members

Transition of care for members

Transition of care: If a member is undergoing treatment, but their current provider isn't in the Premera Blue Cross network, they may be able to continue treatment or specific covered services for a limited time with their existing provider.
Continuity of care: If a member is undergoing treatment, but their current provider is leaving the Premera Blue Cross network, they may be able to  continue to receive treatment or care for specific covered services for up to 90 days with the existing provider.

Prior authorization and pre-approval

Code list

General prior authorization request

Durable medical equipment (DME) request

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

Infusion drugs

Upcoming policies for review

Pharmacy

Pharmacy services prior authorization request form

Referral provider fax form