Browse a wide variety of our most frequently used forms. Can't find the form you need? Contact us.
For additional member forms, view our specific plan pages:
Medicare Advantage plans
Federal Employee Program (FEP) plans
Note: Carewise audit appeals should go directly to Carewise as noted in the letter sent to providers.
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).
BlueCard appeal submission - For out-of-area BlueCard members appealing the home Blue plan.
View our Medicare Advantage page or individual plans page for
additional appeal forms.
Policy reconsideration - Request reconsideration of a coding policy.
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 - Provide information about a patient's other healthcare coverage.
Other coverage questionnaire (out-of-area/BlueCard) - Provide information about an out-of-area/BlueCard patient's other health care 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.
Admission notification and discharge notification
Learn more about submitting
prior authorization, including for DME.
General prior authorization request
Out-of-network exception request - Request in-network benefits for an out-of-network service.
Durable medical equipment (DME)
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 pre-approval request
Opioid attestation– Specific to School Employees Benefits Board (SEBB) members undergoing active cancer treatment, hospice, palliative care, end-of-life, or medically
necessary care who might be exempt from quantity limits. For expedited authorization codes, call Premera pharmacy services at 888-261-1756.
Premera uses ProviderSource ™ to manage data for credentialing, recredentialing, and privileging. ProviderSource is free and requires:
View our practitioner credentialing checklist or the Join Our Network page for more 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.
IRS SS-4 confirmation letter - Include a copy of this letter to show your Employer Identification Number or EIN.
Provider update - Email this 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 day. It also requires all
providers and facilities submit this information to in-network plans.
Unverified providers may be removed from our directory.
Organization/facility credentialing/recredentialing application - To join our provider network as a facility, complete this application
and a W-9 form. Email us your completed documents. The credentialing process typically takes 30 days. Acceptance is based on your application
information and network requirements. If your submitted application is accepted, you'll receive a contract to review and sign. Once you return your signed contract, you’ll receive a counter-signed contract and the effective date of your participation.
Amazon in-network only plan primary care provider (PCP) referral to specialist -
For PCPs to use when referring an Amazon In-network Only Plan member to a specialist. The completed form must be submitted to Premera before the member receives services from a specialist.
Microsoft autism/ABA therapy program treatment plan checklist - For Microsoft members only. The checklist must be completed before claims are processed.