Looking for Premera Medicare Advantage forms?
Here you'll find our most frequently used forms. If you can't find the form you need, 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.
Appeal submission form for contracted providers Resolve billing issues that directly impact payment or a write-off amount.
Appeal/reconsideration form - Premera Medicare Advantage Use for Medicare Advantage patients.
Appeal submission form - BlueCard
Corrected claim cover sheet Correct billing information on a previously processed 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.
Overpayment notification form Notify Premera of an overpayment your office received.
Request to enable real-time claims Add real-time claims submission capability to the estimate tool.
Standard provider 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.
Support Document Cover Sheet - Use this form to submit supporting documentation that is required to process a claim.
Forms for submitting a pre-service review request if a service is medically necessary.
Durable medical equipment (DME)
Home health care
Psychological or neuropsychological testing Submit a request to perform psychological or neuropsychological testing.
FEP prior approval request/response Use for FEP patients to submit required prior approval request for certain procedures.
*This form is used to submit all types of requests for medical necessity.
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 Administration (DEA) certificate and malpractice insurance fact sheet, must be kept current.
Practitioner credentialing checklist Use this checklist to ensure that we receive all of your required credentialing documents to become a participating provider.
Practitioner application Request to join our professional provider network.
Practitioner credentialing/recredentialing addendum Provide us with the your medical record retrieval and practice information.
Behavioral health specialty addendum Provide us with your behavioral health primary areas of clinical expertise.
Dental provider credentialing application Request to join our dental provider network.
W-9 - Use this IRS form to provide us with your current taxpayer identification number (TIN).
Organization/facility credentialing/recredentialing application Request to join our facility provider network.
Amazon in-network only plan primary care provider (PCP) referral to specialist form For PCP's to use when referring an Amazon In-network Only Plan member to a specialist. The form must be completed and submitted to Premera before the member receives services from a specialist.
Confidential exchange of information form Sample form template for the exchange of information between medical and behavioral health providers.
Provider update form Email this form to Premera with new information or changes to your current practice or payment structure.
Dental insurance verification Template for documenting dental benefits when calling customer service for a dental benefit quote.
Dental individual adult copay schedule List of covered dental services and copays.
Healthcare provider biometric screening form For Premera members in the metallic wellness program requesting a wellness biometric screening.
Massage Therapy Prescription Submission Form Request coverage of massage therapy services.
PersonalCare Plan Primary Care Provider Referral Form (web-based or paper form) For primary care providers to use when referring a PersonalCare Plan patient to a specialist outside of the patient's Partner System. The form must be completed and submitted to Premera before the patient receives services from a specialist. Do not use for patients assigned to the UW Medicine Accountable Care Network. Referrals for those patients may only be submitted by the UW Medicine Contracting and Payer Relations Department.
Serious adverse event form Facilities can use this form to report serious adverse events.
Learn about our pharmacy programs and find pharmacy forms.
Policy reconsideration Use to request reconsideration of a coding policy.
Practitioner data sheet Provider specialties that don't require credentialing can use this form to request to join our professional provider network.
W-9 Use this IRS form to provide us with your current taxpayer identification number (TIN).