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.
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.
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.
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.