Get Premera Blue Cross Member Appeal Form 2021-2025

Completing the Premera Blue Cross Member Appeal Form is an essential step for users looking to challenge a decision regarding their healthcare coverage. This guide provides clear, step-by-step instructions to help you successfully fill out the form online.

Follow the steps to complete the appeal form accurately.

1. Press the ‘Get Form’ button to access and open the Premera Blue Cross Member Appeal Form.
2. In Section A, provide your personal information, including first name, last name, date of birth, ID prefix, ID number, suffix, address, group/policy number, city/state, ZIP code, and phone number.
3. If you are submitting the appeal on behalf of another person, complete Section B. Indicate whether you have legal documents to act on the member’s behalf and attach any required documentation if applicable.
4. In Section C, select the appeal category and provide relevant provider information if related to medical services. Details such as provider name, address, date of service, claim number, total charge, and utilization management reference number are required.
5. In Section D, detail what you would like to be reviewed and state the action you want Premera Blue Cross to take. Attach any supporting documents as necessary.
6. In Section E, ensure that both the member’s and authorized person's signatures are provided, along with the dates for these signatures. You may also provide an email address to receive responses electronically.
7. Once you have completed all sections, save the changes and download, print, or share the completed form as needed. Ensure the form is mailed or faxed to the designated address or fax number provided.

Take action today by completing the Premera Blue Cross Member Appeal Form online to ensure your concerns are addressed promptly.