Here you'll find all the Medicare Advantage forms you need. If you have any questions about these forms, please contact us.
Appeal and reconsideration forms
Appeal and reconsideration form for contracted and non-contracted providers. Providers can use this form for level I and level II appeals as well as pre-service denials and payment appeals.
Request for redetermination of Medicare prescription drug denial - Providers and members can use this form to request a redetermination (appeal) of a Medicare prescription drug denial.
Waiver of liability - Include this form with your appeal if you are a non-participating provider.
Referral forms
Care management referral form - Use this form to refer a member to our care management program.
PCP referral form - Use when referring a member to an out-of-network specialist. Referrals to in-network providers no longer need to be submitted to Premera for approval.
Care management forms
Guidelines for bundling admissions - Use this reference guide for situations when admissions are bundled.
Bariatric surgery assessment form - Use this form when planning to request a bariatric surgery procedure for a member.
Physician-supervised weight loss program procedure - Review this criteria when considering a referral request for a bariatric surgery.
Physician-supervised weight loss program documentation - Use this form to help document needed requirements for patients seeking referrals for bariatric surgery.
Detailed explanation of non-coverage - A courtesy form to help you notify patients when services are no longer covered and why. View instructions for this form.
Medicare outpatient observation notice (MOON) - This courtesy form helps facilities explain to patients when they're in observation and not admitted to the facility. CMS requires that facilities provide this form to patients.
Medicare outpatient observation form instructions (MOON) - Instructions for filling out the MOON form.
Notice of Medicare non-coverage - This form is for agencies and skilled nursing facilities to help notify patients when services are no longer covered beyond a certain date. It also explains patient rights and the process for submitting an appeal.
Medical records routing form - Use when you need to send medical records.
Pre-approval forms
Prior authorization form - Use this form for prior authorization requests. You can also submit prior authorization requests online using the prior authorization and referral tool.
Part B drug request form - Use this form when submitting prior authorization requests for Part B medications.
Request for Medicare prescription drug coverage determination - Use for patients appealing Premera's denial of coverage for a prescription drug.
Long-term acute care hospital care management form - Use when requesting approval for long-term acute care.
Skilled nursing facility (SNF) and inpatient (IPR) form - Use when requesting authorization for SNF or IPR.
Financial forms
Check submission form - Use when sending a check to Premera Medicare Advantage.
Provider offset request - Use to initiate an immediate offset when you have an overpayment from Premera Medicare Advantage.