Get Premera Incident Questionnaire

The Premera Blue Cross Incident Questionnaire is essential for ensuring thorough investigation and processing of claims related to incidents and injuries. This guide provides step-by-step instructions for filling out the form online to help expedite your claims experience.

Follow the steps to accurately complete the Premera Incident Questionnaire.

1. Click ‘Get Form’ button to access the questionnaire and open it for completion.
2. Fill out your information in the upper right-hand corner of the form. Ensure all required fields are completed accurately to avoid delays.
3. Include the appropriate ICD-9 Code(s) in the designated area in the upper right-hand corner, ensuring it matches your diagnosis for claim submission.
4. Request the patient to print and complete Sections A through F of the form legibly, including their signature at the end.
5. In Section A, if the incident was not an accident, ask the patient to describe how the injury occurred.
6. Ensure the completed IQ form is submitted separately from any claims to maintain proper processing.
7. Fax the completed form to 425-918-5355 or mail it to Premera Blue Cross at the address provided in the form.
8. Advise the patient that they have 45 days to sign and return the completed form to avoid claim denial.
9. Once all information is accurately filled out, save the changes, download, print, or share the document as needed.

Complete the Premera Incident Questionnaire online today to ensure efficient processing of your claims.