| 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. |
Federal
Employee Program Outpatient Mental Health Treatment
Plan (PDF)
|
Form for members with FEP primary coverage. It
is not necessary to submit this form for members
with FEP secondary coverage, such as Medicare,
unless primary benefits have been exhausted, services
are not covered, or have been denied by the primary
carrier.
Call FEP Customer Service at 1 (800) 962-2731,
before treatment begins to verify the type of
coverage, benefits, eligibility, co-payments,
and deductible.
Fax completed forms to 1 (800) 331-3505. |
Behavioral
Health Treatment Plan Request
|
Treatment plan request form may be completed
using our secure and encrypted online form.
Download
(PDF),
complete the form and return to Regence:
| Fax: |
Regence
Behavioral Health 1 (800) 331-3505 |
| Mail: |
Regence BlueCross
BlueShield of Oregon
PO Box 1271, Mailstop E9H
Portland, OR 97207-9861 |
Treatment
Plan Form Instructions (PDF) |
| 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. |
|
| Claims
& billing forms |
| Corrected
Claim - Standard Cover Sheet (PDF) |
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
|
| 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
|
| 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. |
| Standard
Referral Form (PDF) |
Complete this form (or your own) when submitting
referrals. |
Voucher Overpayment Refund Form (PDF)
|
Use this form to notify Regence of an
overpayment to your office and request a correction.
This form may be completed online, printed and
mailed along with your check to:
Regence BCBSO
Attn: Oregon Claims Refund
P.O. Box 91048
Seattle, WA 98111-9148
|
| Provider
Information Update Form |
Provider
Information Update Form
|
Complete the Provider Information Update
Form using our secure and encrypted online
form. Update or change your details in our
records, including in our Provider Directories
or to submit your National Provider Identifier
(NPI). |
| Pre-authorization
forms |
| Pre-authorization Request Form (PDF) |
Complete this form to facilitate the pre-authorization
process for medical, surgical or DME services. |
| Pre-authorization Information Form (PDF) |
Complete this form to facilitate the pre-authorization
process for home health and ancillary therapies. |
| Pharmacy
forms |
|
| Pharmacy
Prior Authorization Request Form |
Now located on the RegenceRx
Physician Web site. |
| Supply
request forms |
| Online
Supply
Request Form |
Request supplies such as provider
manuals, forms, brochures or patient chart stickers
using our secure and encrypted online form.
Download
(PDF), complete the form and fax to Regence
(503) 225-6911. |
| Miscellaneous
forms |
| Improvement
Suggestion Form (PDF) |
Complete this form to suggest ways
Regence can improve our service to you. Fax completed
forms to (503) 587-3360. |
Application
for Provider Number and Provider File Update (PDF) |
Complete this form to apply for a billing number to
allow us to process your claims. |
| Sample
Non-Covered Services Waiver Form (PDF) |
Use this sample form as a guideline when developing
a waiver form. You may wish to consult with your
legal counsel before adopting this format. |
| WebNotes
for hospitals |
| Subscription Form |
Joining the WebNotes program allows
participating hospitals to
receive immediate electronic notification and
access to
The ConnectionSM newsletter, Administrative
Manual, and other information online. |
|
Information Update Form |
Complete the secure and encrypted online
form to update
your facility information for Regence BCBSO’s
WebNotes. |
| Provider |
Criteria |
Application |
| Practitioners |
Practitioner
credentialing criteria (PDF) (effective 11/1/2007)
|
Oregon Practitioner Credentialing Application (MS Word format)
Fax completed applications to our Credentialing Department at
(503) 225-4808, or mail it to Credentialing, Regence BCBSO, PO Box 1271 MS E9B, Portland, Oregon 97207-1271. |
Organizations
Eligible organizational providers include:
- Ambulatory Surgery Centers
- Hospital Medical Centers
- Home Health Agencies
- Hospice Care Centers
- Skilled Nursing Facilities
- Behavioral Health Care Organizations, including those that provide mental health, chemical dependency, alcohol and drug rehabilitation services.
|
Organization
credentialing criteria (PDF) (effective 11/1/2007)
|
Request an Organizational Provider
Application from your Provider
Relations Representative. |
| Facilities |
|
Universal
Facility Application (PDF)
Mail completed applications to our Credentialing Department at P.O. Box 21267, Mail Stop S555, Seattle WA 98111-3267 |
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 Centers for Medicare & Medicaid Services.
Note: To view and print the documents
listed on this page, you must have the Adobe® Acrobat®
Reader installed. Get more information and/or download
the free Adobe
Acrobat Reader.
