Fillable Provider Appeal Form Follow the steps below to (Premera Blue Cross)

Fill Online, Printable, Fillable, Blank Provider Appeal Form Follow the steps below to (Premera Blue Cross) Form

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Provider Appeal Form Follow the steps below to (Premera Blue Cross)

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Provider Appeal Form

Follow the steps below to submit an appeal request to Premera Blue Cross.

A. Provider information:

Who are you appealing for? Please check: ☐ Provider ☐ Member

Provider (e.g.: doctor’s name, hospital, laboratory):

Address: City/State ZIP code:

NPI: Tax ID #:

Provider contact name: Phone #: Fax #:

B. Member information:

First name: Last name: Date of birth: MM/DD/YY

ID prefix:(see ID information) ID #: Suffix: Group/policy #:

If you’re appealing on behalf of your patient regarding a pre-service denial or a request to reduce member

cost shares, this is known as a member appeal. The member must sign and complete Section C.

C. Member appeal authorization: Who can appeal on your behalf? Check which one applies and sign below.

Provider listed in Section A

Someone else, please provide information below:

First name: Last name: Phone:

Address: City/State: ZIP code:

Release of Healthcare Information and Records

By signing this form, I understand and agree to the following:

Premera Blue Cross, or any of its affiliates (“the Company”), may disclose my health records to the authorized representative

listed on this form.

I understand that the healthcare information may include my benefit, claim, diagnosis, and treatment records including

information about the following sensitive healthcare diagnosis and treatment (you may cross off items you prefer not to

share).

• Alcohol and/or chemical dependency

• Sexually Transmitted Diseases (including HIV/AIDS)

• Genetic information

• Reproductive health (including abortion)

• Gender-affirming care, gender dysphoria, domestic violence, and behavioral health

You can change your mind and withdraw this release at any time by informing the Company in writing at the address listed on page 2. The

Company will make sure the change goes into effect within 5 business days after receiving your withdrawal request and will not be liable

for any information released before your change goes into effect. This release is voluntary. We won’t condition your health plan

enrollment, eligibility for benefits, or claims payment on giving this release. This release lasts 24 months from the signature date or until

the appeal process is complete, whichever is earlier.

Member signature: ______________________________________________________ Date: ______________________________________

Member printed name: __________________________________________________

017953 (03-30-2021)

D. What are you appealing?

Type of request (if known): Please select the one that most applies:

Level I appeal

Pre-service denial (services not yet provided)

Level II appeal

Claim/service processed

Please provide information below:

Date of service: MM/DD/YY Claim number: Total charge:

Utilization management reference #:

(listed on denial letter)

E. Tell us the why you are appealing:

What would you like us to review again? Write in the space below What action do you want us to take? Write in the space below. If

and be sure to attach supporting documents. you need more space, please attach a written statement.

F. Send to the appeals department or clinical appeals, depending on the following:

Clinical related?

• Lack of medically necessary criteria

• Issues with prior authorization

Send to:

Fax: 425-918-4133

Premera Blue Cross

ATTN: Clinical Appeals

P.O. Box 91102

Seattle, WA 98111-9202

Provider contract related?

• Inclusive procedures/clinical edits

• Allowed amount not applied per provider’s contract

• Multiple modifier reimbursements

Send to:

Fax: 425-918-5592

Premera Blue Cross

ATTN: Appeals Department

P.O. Box 91102

Seattle, WA 98111-9202

 



Discrimination is Against the Law

Premera Blue Cross (Premera) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national

origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free aids and services to people with disabilities to

communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print,

audio, accessible electronic formats, other formats). Premera provides free language services to people whose primary language is

not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Civil

Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of

race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals,

PO Box 91102, Seattle, WA 98111, Toll free: 855-332-4535, Fax: 425-918-5592, TTY: 711, Email AppealsDepartmentInquiries@Premera.com.

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is

available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for

Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,

or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building,

Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Language Assistance

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-722-1471 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電

800-722-1471

（

TTY

：

711

）。

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

800-722-1471

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ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 800-722-1471

(телетайп: 711).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.

Tumawag sa 800-722-1471 (TTY: 711).

УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби

мовної підтримки; Телефонуйте за номером 800-722-1471 (телетайп: 711).

    , 

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注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

800-722-1471

（

TTY:711

）

まで、お電話にてご連絡ください。

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ

800-722-1471

(መስማት ለተሳናቸው:

711

XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 800 -722-1471 (TTY: 711).

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(TTY: 711) 

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.

Rufnummer: 800-722-1471 (TTY: 711).

ໂ࢝ຌຊາ࢜

້࢘າລ່າ ່࢚າ࢛ເລົ້າພາࢧາ ຤າລ

ກາ࢛࢜ໍ຤ິກາ࢛ຊ່ລ຋ເࢨຼືອຌ້າ࢛ພາࢧາ, ໂຌ຋࢜ໍ່ເࢧັຽຄ່າ,

ແມ່࢛ມີພ້ອມໃࢨ້່࢚າ࢛. ໂ࢚ຣ

800-722-1471 (TTY: 711)

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 800-722-1471 (TTY:

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero

711).

ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-722-1471 (ATS : 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 800-722-1471 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-722-1471 (TTY: 711).

800-722-1471 (TTY: 711).

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An independent licensee of the Blue Cross Blue Shield Association 037397 (11-06-2019)

توهج

          

Fillable Provider Appeal Form Follow the steps below to (Premera Blue Cross)

Fill Online, Printable, Fillable, Blank Provider Appeal Form Follow the steps below to (Premera Blue Cross) Form

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