All forms must be signed, then either faxed or mailed.
General forms
FEP Forms (fepblue.org) - A one-stop source for FEP claim forms.
FEP fax cover sheet - Include this cover sheet when submitting a corrected claim, mailing or faxing medical records for a claim, or submitting an appeal.
Overpayment notification form (.pdf) – Notify Premera FEP of an overpayment your office received.
Appeals
Provider appeal form - Form for providers to use to dispute a denied claim or processed claim that negatively impacts your payment. Please do not use this form for corrected claims, duplicate claim denials,
claims requests for additional information, coordination of benefits, or claims submission inquiries, as these are not considered provider appeal issues.
Prior approval
Prior approval request form_Alaska or Prior approval request form_Washington – Use to submit a pre-service request.
Precertification/Concurrent Review Request Form_Alaska or Precertification/Concurrent Review Request Form_Washington (except Clark County)– Use to
submit an inpatient admission and concurrent review precertification request.
ABA prior approval request form_Alaska or ABA prior approval request form_Eastern Washington – Use to submit an applied behavior analysis (ABA) prior
approval request.
DME prior approval request form_Alaska or DME prior approval request form_Washington - Use for durable medical equipment (DME) prior approval requests.