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.

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

The Zung Self-Rating Depression Scale is a screening tool to identify symptoms of depression in adults. The first page contains the screening questions; the second page contains the scoring key.

Automatic Deposit (EFT/ACH Credits) Authorization and Contact Information (PDF)

Complete and return this form to receive email notification when an electronic funds transfer (EFT) is made or when an Electronic Remittance Advice (claims voucher) is posted in the Provider Center.

Complete this form to file a corrected claim.  Instructions: 

• Attach a copy of the original claim
• Include the claim number that needs to be corrected
• Mail the form with corrected claim to the address on the back of the member’s card

Questions on this form or other issues regarding flu shots, please contact Provider Customer Service.

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

Complete this form when submitting information to support a claim. Instructions:

• Cover sheet ensures documentation is "attached" to the correct claim
• Expedites processing
• Mail the form with additional documentation to the address on the back of the member's card

Providers

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 (888) 335-3002. Please do not mail paper applications to Regence.

Practitioner Credentialing Criteria for Participation and Termination (PDF) (Effective 7/1/2012)

Practitioner Credentialing Application (PDF)

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
PO Box 21267 M/S 5555
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.

Dental

Review the credentialing criteria and complete an application.

Return completed and signed Practitioner Credentialing Applications by email or Fax to (888) 335-3002.

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

Practitioner Credentialing Application (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.

Pre-authorization Request Form

Medical, surgical or DME services:

• Secure online form
• 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.

Expedited is defined as: when the Member or his/her physician believes that waiting for a decision under the standard time frame could place the Member’s life, health, or ability to regain maximum function in serious jeopardy.

Submit completed forms:

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 (855) 232-0088

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
• Download and submit by fax to Regence Behavioral Health at 1 (888) 496-1540:
  • For 2012 dates of service (PDF)
  • For 2013 dates of service (PDF)

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.

Notice of Medicare Non-Coverage (NOMNC) forms

CMS requires the Notice of Medicare Non-Coverage (NOMNC) form to be issued for every discontinuation of SNF level of care, two days prior to the end of services. The NOMNC form informs the member of the date he or she meets criteria for SNF care and describes the member’s appeal rights if they disagree with that decision.

It is important to use the correct form based upon the member’s coverage and location of services being rendered. Use of another health plan’s notification form for Regence members is not considered valid by CMS. The NOMNC should be faxed to Regence at 1 (855) 240-6498 as soon as possible after the form is signed.

• Idaho and Asotin County, Washington NOMNC Form (PDF)