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Forms
Form Description Instructions
Alcohol Use Disorders Identification Test (AUDIT) (PDF)

The Alcohol Use Disorders Identification Test (AUDIT) was produced by the National Institute on Alcohol Abuse and Alcoholism, a component of the National Institutes of Health, and is endorsed by the World Health Organization (WHO) as a screening tool to identify heavy alcohol use.

  
Authorization to Disclose Protected Health Information (PDF)

Patient authorization for health care provider to disclose health information pertaining to mental health treatment, claims, and other medical information, to Regence.

Complete to allow disclosure of protected health information to Regence.

Members must complete a separate authorization if they wish Regence to release health information to other entities. This form is accessible on myRegence.com.

Zung Self-Rating Depression Scale (PDF)

The Zung Self-Rating Depression Scale is a screening tool to identify symptoms of depression in adults. The ZDS is also useful as an outcome measurement tool to track a client's progress over time. The first page contains the screening questions; the second page contains the scoring key.

  

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Claims & Billing Forms
Form Description Instructions
Automatic Deposit (EFT/ACH Credits) Authorization and Contact Information (PDF)
• Enroll in electronic funds transfer to have claim payments deposited directly into your bank account.
• Enrollment will require that you also receive your remittance advices electronically.
  		• Print and complete all fields on the form
  		• Return to Regence using one of the methods listed on the form
    Appeal Form for Provider Billing Dispute and Medical Necessity Denial (PDF) Form used by physicians and other health care professionals to appeal a claim payment decision. Note: Do not use this form to submit a corrected claim or a member appeal.  
    Coordination of Benefits (PDF) Coordination of Benefits (COB) enables your patients to receive benefits from all health insurance plans they are covered under. Completion of this form will help us process claims correctly.
  		• Member must complete and sign the form.
  		• Send completed form to the member's BlueCross and/or Blue Shield plan.
    Corrected Claim Cover Sheet (PDF) This form was designed to facilitate the submission of a claim. Simply complete the form; attach a copy of the original claim. Submit the form with corrected claim to the address on the back of the member’s card. Using this form will help us quickly identify this as a corrected billing and forward it on to the appropriate area for reprocessing.
  		• Complete all applicable fields on the form.
  		• Make sure you include the claim number that needs correcting.
  		• Indicate the reason(s) the claim should be corrected (corrected charges, diagnosis, patient information, etc.)
  		• Indicate if submitting supporting documentation.
    Incident Report (PDF) Regence BlueShield members will receive this form if the condition being treated requires investigation for third party liability. The member has 45 days to complete, sign, and return the form to Regence BlueShield. If the member does not return the form within the required time period and the services are being denied, the providers’ office can bill the patient for services.
  		• Check to see if the condition is one we investigate. If yes, the member will need to complete the form.
  		• If the condition is one we do NOT investigate, the form is not necessary.
  		• Member must complete and sign the form.
  		• Do not copy completed form and send in for every claim.
  		• Submit the form only when requested- see voucher for message code indicating one is needed.
    Multiple Coverage Inquiry (PDF) Members will periodically receive this form to notify Regence BlueShield of any other medical insurance coverage for themselves or any of their dependents. Members must return the form within the required period or the charges will be denied as patient responsibility for this claim and any future claims until the form is submitted.
  		• Member must complete and sign the form.
  		• Ask for other insurance information periodically and update your records.
  		• Have blank copies in office. If member neglects to complete and sign, at next visit ask the member to complete and sign so you can submit.
    Overpayment Recovery Process and Overpayment/Voucher Deduction Request forms

    Complete the Overpayment/Voucher Deduction Request forms as outlined in the Overpayment Recovery process.

    		 
    Notification of Covering Provider (PDF) Use this form when you have providers within your office or from another location, that you have arrangements with to be ‘on-call’ or covering for a provider within your office. This form should ONLY be used if the Tax ID’s are different. Locum Tenens, Temporary Providers, or PCP’s under the same TAX ID are excluded. By using this form, our system can be updated to recognize the on call or covering provider without requiring a referral.
  		• Complete the covering provider information. This person(s) will be on call or covering for you.
  		• Complete the information for who is requesting this change.
  		• Sign and date the form.
  		• Fax or mail the form to the addresses or number(s) on the form.
    Standard CHITA Referral Form (PDF) This is a standard referral form used by providers statewide. You can also find this form on the Washington Healthcare Forum. Your office can use this form or your own, when submitting referrals.
  		• Complete the referring to and from information.
  		• Complete the member’s information.
  		• Indicate what action is requested.
  		• Check ‘Assume Management’ if applicable.
  		• List any restrictions or itemizations of procedures if applicable.
  		• Sign form and submit.
    Supporting Documentation Form (PDF) This is a standard cover sheet for submitting medical information in support of a claim. Using this cover sheet will ensure that documentation is “attached” to the right claim(s) and will expedite processing.

    You may also use this form when you know in advance that Regence BlueShield requires a report (such as an unlisted procedure code). If you have the claim number, you may also use this form to submit supporting documentation. If we have requested supporting documentation the voucher will indicate when we require additional information.
  		• Complete all fields on the form.
  		• Include claim number on form when submitting.
  		• Do not use for corrected billings or billing disputes.
  		• Indicate if claim was submitted electronically if applicable.
  		• Complete all member information.
  		• Include the office contact information.
  		• Identify in the comment section, what type of documentation you are attaching.
    Miscellanous    
    Annual Wellness Visit Program Enrollment Form (PDF)

    Regence MedAdvantage contracted primary care specialty-type providers may enroll in the Annual Wellness Visit Program.

    		  
    Sample – Non-covered Member Consent Form (PDF)

    Use this sample form as a guideline when developing a member consent form. You may wish to consult with your legal counsel before adopting this format.

    Participating providers must hold harmless any amount determined by Regence to be not medically necessary. Regence will consider a member consent form obtained by the provider of the primary service valid for all associated claims (e.g., anesthesia, pathology, laboratory, hospital) if the primary provider indicates a consent form has been signed.

    		 

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    Contracting and credentialing Forms

    Provider Definition Criteria Forms

    Practitioners

    Physicians and other health care professionals

    Review the credentialing criteria and complete an application.

    Return completed and signed Practitioner Credentialing Applications by email or Fax to 1 (888) 335-3002. Please do not mail paper applications to Regence.

    Practitioner Credentialing Criteria for Participation and Termination (PDF)
    (Effective 1/1/2012)

    Washington Practitioner Application (PDF)

    ProviderSource® is a free service hosted by OneHealthPort™ to help Washington healthcare providers manage provider data used for credentialing and privileging.  You may use ProviderSource to submit your application online. Note: If you use ProviderSource to submit an application please notify our credentialing department.

    TriWest/TRICARE

    TriWest Healthcare Alliance (TriWest) is contracted with the U.S. Department of Defense for the administration of the TRICARE program in the West Region.

     

    		  

    Complete both of the following:

    Organizations

    All organizational providers (facilities) are required to complete the credentialing process prior to contracting with Regence. The recredentialing process must also be completed at a minimum of every three years.

    Review the credentialing criteria and complete an application.

    Return completed Universal Facility Applications to:

    Regence Credentialing Department M/S S555
    P.O. Box 21267
    Seattle, WA 98111-3267

    Fax: 1 (888) 335-3002
    Email

    Organizational Provider Credentialing Criteria for Participation and Termination (PDF)
    (Effective 1/1/2012)

    Organizational Provider/ Facility Credentialing/ Recredentialing Application (PDF)

     

    Hospital and Free-Standing Facility Based Practitioner Information Form

    Practitioner who practices exclusively within a hospital setting, inpatient setting, or free-standing facility setting, meets our credentialing and contracting criteria and provides care for Regence members only as a result of members being directed to the hospital or other inpatient setting.

    Use this form when a provider is being added to a hospital, inpatient or free-standing facility location.

    Return completed Hospital and Free-Standing Facility Based Practitioner Information Form to the address or fax number listed on the form.

    		   Hospital and Free-Standing Facility Based Practitioner Information Form (PDF)

    Dental

     

    Review the credentialing criteria and complete an application.

    Return completed and signed Practitioner Credentialing Applications by email or Fax to 1 (800) 331-3505.

    Practitioner Credentialing Criteria for Participation and Termination (PDF)
    (Effective 1/1/2012)

    Washington Practitioner Application (PDF)

     

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    Medical Pre-Authorization Forms
    Form Description Instructions

    Pre-authorization Request Form

    Medical, surgical or DME services:

    Home Health and Ancillary Therapies:

    • PDF version to print and fax

    This form is used when a condition requires a pre-authorization. A limited number of services require a pre-authorization.

    Submit completed forms:

    • Securely online, or
    • By Fax to:
           
        •

    1 (877) 663-7526 for Uniform Medical Plan (UMP) members
        •

    1 (800) 453-4341 for all other members
    Pre-Authorization Fax Cover Sheet This form is used when faxing the Pre-Authorization Request Form Use the Pre-Authorization Fax Cover Sheet to fax your Request form or supporting documents.

    Statement of Medical Necessity for Oncotype DX (PDF)

    This form is used to facilitate medical necessity for Oncotype Dx® Breast Cancer Assay. Codes include S3854 and 84999.

    		 Fax completed forms to 1 (800) 453-4341
    Behavioral Health Pre-authorization Forms
    Form Description Instructions

    Outpatient Treatment Plan Request (PDF)

     

     

    This form is for Federal Employee Program (FEP) members. 

    A treatment plan is requested, but not required, for members with FEP primary coverage.

    Call FEP Customer Service at 1 (877) 668-4654 in order to verify the type of coverage, benefits, eligibility, co-payments, and deductible.

    Please fax the completed form to 1 (888) 496-1540.
    Behavioral Health Treatment Plan Request

    This form is for members who require an authorization for behavioral health outpatient treatment, including chemical dependency.

    Submit this form to Regence for authorization of continued services.

    Please call Regence Behavioral Health Customer Service at 1 (800) 780-7881 for any authorization questions. 

    Complete the Treatment plan request form securely online or you may download the form (PDF) and submit by fax to Regence Behavioral Health 1 (888) 496-1540.

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    Medicare Forms for Hospital or Skilled Nursing Facility Discharges:

    Medicare requires specific forms to be issued for every discharge from a hospital, skilled nursing facility or home health.

    Hospital discharge notice
    The An Important Message From Medicare About Your Rights form, along with additional information can be obtained from Centers for Medicare & Medicaid Services (CMS).

    Notice of Medicare Non-Coverage (NOMNC) forms

    It is important to use the correct Regence form based upon your geographic location. Use of another health plan’s notification form for Regence members is not considered valid by CMS.

    Note: The name, address and telephone number of the provider that delivers the notice must appear above the title of the form.

    Instructions - Skilled Nursing Facility NOMNC forms

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    Provider Information Update Forms
    Form Description Instructions
    Notification of Covering Provider Use this form when you have providers within your office or from another location, that you have made arrangements to be 'on call' or covering for a provider within your office. This form should ONLY be used if the Tax ID's are different. Locum Tenens, Temporary Providers, or PCPs under the same TAX ID are excluded. By using this form, our system can be updated to recognize the on call or covering provider without requiring a referral.
  		• Complete the covering provider information. This person(s) will be on call or covering for you.
  		• Complete the information for who is requesting this change.
  		• Sign and date the form.
  		• Fax or mail the form to the addresses or number(s) on the form.
    Provider Information Update Form

    Complete the Provider Information Update Form when:

    • A provider leaves or joins your clinic or practice
    • You have a change to your organization's address, phone number, tax identification or National Provider Identifier number

    The form can easily be submitted online or printed and faxed.

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