Provider Forms

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:

Individual plans

Federal Employee Program (FEP) plans

Providers can submit an appeal for the following reaons:	Please don't submit appeals for:
Clinical edit disagreements (include supporting documentation showing correct billing) Medical necessity denials (provider write-offs) Allowed amounts that disagree with the contracted rate, multiple same-day reductions, denials for inclusive procedures, or OrthoNet denials Claims denied for timely filing	Billing errors Duplicate or eligibility denials Corrected claims Claims denied for needing medical records, incident questionnaires, or other additional processing info Other coverage denials like coordination of benefits, worker’s comp or subrogation

Note: Carewise audit appeals should go directly to Carewise as noted in the letter sent to providers.

Appeals

Premera commercial plans provider appeal form - 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).

Premera individual plans provider appeal form

BlueCard plans provider appeal form- For out-of-area BlueCard members appealing the home Blue plan.

Federal Employee Program (FEP) plans provider appeal form

Policy reconsideration

Policy reconsideration - Request reconsideration of a coding policy.

Claims and billing

Processing or correcting claims

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 enrollment - 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.

Billing

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.

Care management and prior authorization

Care management

Admission notification and discharge notification

Prior authorization and pre-approval

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)

Infusion drugs

Pharmacy

Pharmacy pre-approval request

Credentialing

How to apply

To apply, you can request an individual contract or join one of our contracted independent practice associations or medical groups once you meet our credentialing criteria and standards.

Submit your application using our hard-copy credentialing application until we transition to the new vendor, CAQH. Find out more about the CAQH transition.

Use our provider credentialing checklist to make sure you've submitted all necessary information.

Submit your application by fax, email, or mail:

Fax: 425-918-4766
Email: credentialing.updates@premera.com
Mail: PO Box 327 – MS 263, Seattle, WA 98111–0327

For dental and facility providers

Dental provider application - Request to join our dental network
Organization/facility credentialing/recredentialing application - Request to join our provider network as a facility

Update provider information

Update your information with Premera by using our provider update form.

Visit our Update Provider Information web page to update your provider directory listing through Better Doctor, make sure your CMS National Plan & Provider Enumeration System (NPPES) profile is current, and much more.