| 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 (FEP) Outpatient Mental Health
Treatment Plan (PDF) |
This form is only for members with FEP primary
coverage. Please call FEP Customer Service before
treatment begins to verify patient coverage,
benefits, eligibility, co-payments, and deductible. |
| 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
and billing forms |
| Refund
Notification (PDF) |
Complete this form to notify
Regence of an overpayment to your office and
request a correction. This form may be printed
and mailed along with your check to:
Regence BlueCross BlueShield of Utah
Attn: Cash Management - Dept #2
PO Box 30270
Salt Lake City, UT 84130-0270
|
| Automatic
Deposit (EFT/ACH Credits) Authorization Agreement (PDF) |
Complete this form to authorize funds to
be deposited directly into your bank account.
Please return the form with an original deposit
slip or voided check.
If you are a Medicare B provider you will also
need to complete the AUTHORIZATION
AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)
form. |
| Corrected
Claim - Standard Cover Sheet (PDF) |
Complete this form to facilitate the submission
of a corrected claim. Submitting this form with
your corrected claim will help us quickly identify
this as a corrected billing and forward it on
to the appropriate area for reprocessing. If
available, please be certain to include the original
claim number.
Completed forms should be sent to:
Regence BlueCross BlueShield of Utah
PO Box 30270
Salt Lake City UT 84130-0270 |
| Incident
Report (PDF) |
Members who need medical care as a result
of an injury or accident may be asked to complete
this form and submit it to Regence BlueCross
BlueShield of Utah.
| Instructions: |
- Check to see if the condition is
one we investigate. If yes, the member
will need to complete the form.
- If the condition is one we do NOT
investigate, the form is not necessary.
- Member must complete and sign the
form.
- Do not copy completed form and send
in for every claim.
- Submit the form only when requested-
see voucher for message code indicating
one is needed.
|
|
| Other
Insurance Information (PDF) |
Employees who are covered under a spouse’s
health plan as well as a Regence BCBSU plan, or
a Regence HealthWise plan, or a Regence ValueCare
plan should complete this form and mail it to Regence
BCBSU. |
| 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. |
| Required
Information Review (PDF) |
This form must
be used by Home Health agencies to pre-authorize
services and supplies or request any visit or duration
extensions for members. Fax completed forms along
with any supporting documentation to (801) 333-6511. |
| Standard Referral Form (PDF) |
Your office can use the Community Health Information Technology Alliance (CHITA) Standard Referral Form or your own, when submitting referrals. |
| Supporting
Documentation - Standard Cover Sheet (PDF) |
This is a standard cover sheet for submitting
medical information in support of a claim. Supporting
documentation may be required (such as when billing
an unlisted procedure code), or may be requested
for review of a previously submitted claim. Using
this cover sheet will ensure that documentation
is “attached” to the right claim(s)
and will expedite processing.
If we are requesting additional information,
please call Customer Service prior to submitting
documentation to clarify what information is needed.
Information not requiring medical review, such
as an onset date, can be accepted over the phone.
If documentation is required, please be certain
to include the claim number for accurate processing.
Completed forms should be sent to:
Regence BlueCross BlueShield of Utah
PO Box 30270
Salt Lake City UT 84130-0270 |
| Provider
Billing Dispute and Medical Necessity or Investigational
Denial Appeal Form (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. |
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.
