| 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. |
| Regence
Behavioral Health Outpatient Treatment Plan
Request (PDF) |
This form is for members with Regence BlueCross
BlueShield of Utah coverage who require an authorization
for behavioral health outpatient treatment. Please
call Regence Behavorial Health Customer Service
at 1 (800) 780-7881 for any authorization questions. |
| 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 at 1
(877) 668-4657 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 |
| Overpayment Recovery Process and Overpayment/Voucher Deduction Request forms |
Complete the Overpayment/Voucher Deduction Request forms as outlined in the Overpayment Recovery process.
|
Important
information regarding Electronic Funds Transfers
(EFT)
|
Please read this important information prior
to submitting your request for EFT.
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.
|
|
| 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 |
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." |
| 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 Plans notification form for Regence members
is not considered valid by CMS.
