Forms

Prior authorization

Prior authorization request form - Individual plans only use one prior authorization request form for all services including DME and provider-administered infusion drugs.

Claims, billing, appeals

• Provider appeal submission form with authorization – Member authorization is embedded in the form for providers submitting on a member's behalf. See section C.
• Corrected claim cover sheet – Correct billing information on a previously processed claim.
• Policy reconsideration form – Request reconsideration of a coding policy
• Standard provider letter for refunds under $25 - Use this form to document refunds under $25. (We don't send letters requesting a refund for overpayment of less than $25 per claim).
• Supporting documentation cover sheet - Submit supporting documentation required to process a claim.
• Overpayment notification form – General instructions for providers
• Balance billing dispute form – Providers or facilities not contracted with LifeWise can use this form to submit a dispute request for the federal No Surprises Act or WA Balance Billing Protection Act. The form must be received by Premera within 30 calendar days from receipt of the original payment notification. Find out more about the federal No Surprises Act and WA Balance Billing Protection Act.

Credentialing and updates

See the Join Our Network page for credentialing forms and information.

Visit our Update Provider Info page for resources to update your provider information and directory listing.