| 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. |
| 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 |
| 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) |
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Enroll in electronic funds transfer to have claim payments deposited directly into your bank account. |
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Enrollment will require that you also receive your remittance advices electronically. |
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Print and complete all fields on the form |
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Return to Regence using one of the methods listed on the form |
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| 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. |
| 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.
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| 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. |
| Overpayment Recovery Process and Overpayment/Voucher Deduction Request forms |
Complete the Overpayment/Voucher Deduction Request forms as outlined in the Overpayment Recovery process. |
| 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 |
Contracting and credentialing forms
Note: The term “Practitioner” is used on credentialing forms and applications to identify physicians and other health care professionals.
| Hospital-Based
Practitioner Information Form |
Hospital-Based
Practitioner Information Form (PDF) |
Use this form when a provider is
being added to a hospital-based facility. Regence
BlueCross BlueShield of Utah defines Hospital Based
Practitioners as, “Practitioners
who practice exclusively within a hospital setting,
meets our credentialing and contracting criteria
and provides care for Regence BlueCross BlueShield
of Utah members only as a result of members being
directed to the hospital or other inpatient setting." |
| 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. |
| 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. |
| Medical Pre-authorization
forms |
| Form |
Description |
Instructions |
Pre-authorization Request Form
Medical, surgical or DME services:
Home Health and Ancillary Therapies:
- PDF version to print and fax
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This form is used when a condition requires a pre-authorization. A limited number of services require a pre-authorization. |
Submit completed forms:
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Securely online, or |
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By Fax to: |
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1 (800) 453-4341 |
|
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 Outpatient 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 (888) 496-1540 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 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. |
Medicare Forms for Hospital or
Skilled Nursing Facility Discharges:
Medicare requires specific forms to be issued for every discharge from
a hospital, skilled nursing facility or home health.
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
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
Note: To print a PDF document, you need Adobe® Reader®. Download it now for free.
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