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Forms

Behavioral health forms
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.

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

Behavioral Health Practitioner Survey (PDF) The information you share about your practice, specialties and areas of expertise helps us to provide our members with the information they need to make informed decisions about their health care and who they select for services.
Zung Self-Rating Depression Scale (PDF)

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.

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Claims and billing forms
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.

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
    Email notification of EFT or Electronic Remittance Advice (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.

    If you submit your claims electronically, corrected claims must also be submitted in an electronic format. Learn more.

    If you do not submit claims electronically yet, please use our: Corrected Claim - Standard Cover Sheet (PDF)

    Complete this form to file a corrected claim if you submit claims on paper. 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
    Coordination of Benefits Questionnaire (PDF) Complete this form when members are covered by more than one health insurance policy. This will help us process claims correctly.
    Flu Shot Clinic Reimbursement Form

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

    Overpayment Recovery Process and Overpayment/Voucher Deduction Request secure form

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

    Standard Referral Form (PDF) Complete this form (or your own) when submitting referrals.
    Supporting Documentation - Standard Cover Sheet (PDF)

    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

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    Contracting and Credentialing Forms

    Type Instructions Criteria Forms

    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

    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

    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 (888) 335-3002.

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

    Practitioner Credentialing Application (PDF)

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    Miscellaneous forms
    Provider Relations Provide anonymous feedback to Provider Relations using our secure feedback form.
    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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    Medical Pre-authorization forms
    Form Description Instructions

    Pre-authorization Request Form

    Medical, surgical or DME services:

    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:

    Securely online, or
    By Fax to:
           
       

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

       

    1 (855) 232-0088 for all other members

        1 (855) 240-6498 for requests that meet the definition of expedited

    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 Pre-authorization forms
    Form Description Instructions

    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 through June 30, 2014.

    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:

     

    Provider Information Update 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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    Medicare Forms for Hospital or Skilled Nursing Facility Discharges:
    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

    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.

    Members have the right to a fast track review by a Quality Improvement Organization (QIO) if they appeal the discontinuation of their SNF coverage.