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 - 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
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.