For your convenience, we’ve categorized our most frequently used forms below. If you can’t find the form you need or require further assistance, 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.
Appeals Submission Form - For Contracted Providers - Use this form to resolve billing issues that directly impact payment or a write-off amount.
Appeals Submission Form – BlueCard
Corrected Claim Cover Sheet - Use this form to correct billing information on a previously processed claim.
Incident Questionnaire - Use this form when a patient has sustained an injury or was involved in an accident.
Other Coverage Questionnaire Enrollment - Use this form to provide information about other healthcare coverage a patient may have.
Overpayment Notification Form - Use this form to notify Premera of an overpayment your office received.
Request to Enable Real-Time Claims - Use this form to add real-time claims submission capability to the estimate tool.
Standard Provider Letter for Refunds Less Than $25 - We do not 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.
Use the following forms to submit a pre-service review request if a service is medically necessary.
Generic Pre-service Review Request*
Out-of-Network Provider Pre-service Review Request
DME Pre-service Review Request
Home Health Pre-service Review Request
*This form is used to submit all types of requests for medical necessity.
Psychological or Neuropsychological Testing - Testing Form - Use this form to submit a request to perform psychological or neuropsychological testing.
FEP Prior Approval Request/Response - Use this form for FEP patients to submit required prior approval request for certain* procedures.
EHA Form - Use this form when completing an Enrollee Health Assessment patient visit.
ProviderSource™ - A free service to help healthcare practioners manage practitioner data used for credentialing, recredentialing and privileging. Effective Aug. 1, 2013, new practitioners applying for participation with Premera are required to complete an online ProviderSource application as part of Premera's credentialing process.
Behavioral Health Specialty Addendum - Use this form to provide Premera with a practioner's behavioral health primary areas of clinical expertise.
Important: Effective Nov. 1, 2013, new dental practitioners applying for participation with Premera are required to complete an online ProviderSource application as part of Premera's credentialing process.
Organization/Facility Credentialing/Recredentialing Application - Use this form to request to join Premera's facility provider network.
Internal Revenue Service W-9 - Use this form to provide Premera with your current Taxpayer Identification Number (TIN) information.
Contracted Provider Information Changes - Premera contracted providers can email this form to Premera with new information or changes to their current practice or payment structure.
Non-Contracted Provider Information Changes - This form is for non-contracted providers to notify Premera of any new information or changes to their current practice.
Amazon In-Network Only Plan Primary Care Provider (PCP) Referral to Specialist Form
Dental Insurance Verification - Use this form as a template for documenting dental benefits when calling customer service for a dental benefit quote.
Healthcare Provider Biometric Screening Form - This form is for Premera members in the Metallic Wellness Program who are requesting a wellness biometric screening.
Policy Reconsideration - This form should be used to request reconsideration of a coding policy.
Practitioner Data Sheet - Provider specialties (audiologists, etc.) that don’t require credentialing can use this form to request to join Premera’s professional provider network.
Serious Adverse Event Form - Facilities can use this form to report Serious Adverse Events.