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 submission form 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. See section C.
2020 Individual Plan clinical appeal submission form with authorization - Member authorization is embedded in the form for non-contracted providers. See section C.
Appeal/reconsideration form - Premera Medicare Advantage - For Medicare Advantage patients.
Appeal submission form - BlueCard
Balance billing protection act dispute form – Providers or facilities not contracted with Premera can use this form to submit a balance billing dispute request. The form must be received by Premera within 30 calendar days from receipt of the original payment notification. Find out more about the Balance Billing Protection Act.
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.
General prior authorization request
2020 Individual Plan prior authorization request
Out-of-network exception request - For
out-of-network providers to request in-network benefits applied to their service.
Durable medical equipment (DME)
FEP prior approval request/response
Total Joint Replacement Exception Request (Washington small group, 1-50 employees) - Use this form if a (small group) member requests to use a provider and/or facility that isn’t a Premera-Designated Center of Excellence for total knee or hip replacement.
Admission notification and discharge notification
Premera uses ProviderSource ™ to manage data for credentialing, recredentialing, and privileging. ProviderSource is a free service and requires:
Note: Washington House Bill 2335 went into effect on June 1, 2018, and requires the following:
Important: Many Washington counties are closed to accepting new providers. Check the Washington Network Closure Matrix before applying.
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).
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 form must be completed and submitted to Premera before the member receives services from a specialist.
Confidential exchange of information - Sample form template for the exchange of information between medical and behavioral health providers.
Provider update - Email this form to Premera with new information or changes to your current practice or payment structure.
Healthcare provider biometric screening - For Premera members in the metallic wellness program requesting a wellness biometric screening.
Massage therapy prescription submission - Request coverage of massage therapy services.
Microsoft autism/ABA therapy program treatment plan checklist - For Microsoft members only. The checklist must be completed before
claims are processed.
PersonalCare Plan PCP referrals: Starting January 1, 2018, all providers within a Premera PersonalCare Partner System must submit referrals using the new online referral tool. The PersonalCare Plan paper referral form is no longer available. Contact your Premera Partner System liaison if you have questions or need help accessing or using the tool. To learn how to use the new tool, watch the training webinar and read the FAQ.
NOTE: Don't use this form for patients assigned to the EvergreenHealth Partners OR UW Medicine Accountable Care Network.
For UW Medicine patients: Only the UW Medicine Contracting and Payer Relations Department can submit referrals for those patients.
EvergreenHealth Partners: Please reach out to the patient's EHP representative for assistance.
Policy reconsideration - 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 - Provide us with your current taxpayer identification number (TIN).
Learn about our pharmacy programs and find pharmacy forms