Regence BlueCross BlueShield of Oregon Provider Library

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Behavioral health forms
Claims & billing forms
Contracting and credentialing forms
Hospital-Based Practitioner Information Form
Medical pre-authorization
Medicare forms for discharge
Miscellaneous forms
Pharmacy forms
Pre-authorization forms
Provider Information Update Forms
Surgical Safety Checklist
TMJ Treatment Records of Request

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.
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

Appeal Form for Provider Billing Dispute and Medical Necessity Denial (PDF)

Use this form to submit an 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

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

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.

Overpayment Recovery Process and Overpayment/Voucher Deduction Request Form

Complete the Overpayment/Voucher Deduction Request forms 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

Contracting and Credentialing Forms

Note: The term “Practitioner” is used on credentialing forms and applications to identify physicians and other health care professionals.

Type	Instructions	Criteria	Forms
Provider Physicians and other health care professionals	Review the credentialing criteria and complete an application. Return completed applications to: Regence Credentialing Department M/S E9B PO Box 1271 Portland, OR 97207-1271 Fax: 1 (888) 335-3002 Email	Practitioner Credentialing Criteria for Participation and Termination (PDF) (Effective 1/1/2012)	Oregon Practitioner Credentialing Application (PDF)
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: Oregon Practitioner Credentialing Application (PDF) TRICARE Supplemental Credentialing Questionnaire
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 applications to: Regence Credentialing Department M/S 36 PO Box 30270 Salt Lake City, UT 84130 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 applications to Fax: 1 (800) 331-3505, or by mail to: Regence Dental Services PO Box 21267 M/S 513 Seattle, WA 98111	Practitioner Credentialing Criteria for Participation and Termination (PDF) (Effective 1/1/2012)	Oregon Practitioner Credentialing Application (PDF)

Miscellaneous forms
Annual Wellness Visit Program Enrollment Form (PDF)	Regence MedAdvantage contracted primary care specialty-type providers may enroll in the Annual Wellness Visit Program.
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 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.

Medicare Forms for Hospital or Skilled Nursing Facility Discharges

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

Hospital discharge notice

The An Important Message From Medicare About Your Rights form, along with additional information can be obtained from the 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
		•	Oregon NOMNC (PDF)
		•	Clark County, Washington NOMNC (PDF)

Pharmacy forms
Pharmacy Prior Authorization Request Form	Now located on the RegenceRx Physician Web site.

Medical Pre-authorization Forms

Form Description Instructions

Pre-authorization Request Form

Medical, surgical or DME services:

Secure online form

PDF version to print and fax

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

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 Mental Health Treatment Plan (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.

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 Search or to submit your National Provider Identifier (NPI).

Surgical Safety Checklist
Surgical Safety Checklist (PDF)	We recommend and support the use of this Oregon Patient Safety Commission checklist for surgical procedures to avoid complications and errors.

Dental - TMJ
TMJ Treatment Records of Request (PDF)	Print and mail this form along with a claim for TMJ services

Note: To print a PDF document, you need Adobe^® Reader^®. Download it now for free.


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