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.
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 non-contracted providers (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.
Request to enable real-time claims - Add real-time claims submissions to the estimate tool.
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.
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.
Practitioner credentialing/recredentialing addendum - Provide us with 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).
Practitioner data sheet - Provider specialties that don't require credentialing can use this form to request to join our professional provider network.
Provider update - Email this form to Premera with new information or changes to your current practice or payment structure.
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 60-90 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.