| Behavioral
Health Forms |
| Form |
Description |
Instructions |
| 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. |
Complete to allow disclosure of protected health information to Regence. |
| Behavioral
Health Referral Request Regence BlueShield - Do not use for Boeing
or Federal Employee Plan members. |
Use this form for Selections members ONLY for all outpatient
mental services and all levels of chemical dependency. |
| |
Do not use this form for a Boeing employee or Federal Employee
Plan (FEP) member. |
| |
Complete this form within the first 3 days of seeing member for
the initial visit. |
| |
Indicate procedures. |
| |
Fax to Regence BlueShield – the number is on the form. |
|
| Behavioral
Health Referral Request For Regence BlueShield Employees |
Use this form for Regence BlueShield employees who have
the Selections plan for all outpatient mental services and all levels
of chemical dependency. |
| |
Do not use this form for a Boeing employee. |
| |
Complete this form within the first 3 days of seeing member for
the initial visit. |
| |
Indicate procedures. |
| |
Fax to Regence BlueShield – the number is on the form. |
|
| Federal
Employee Program (FEP) - Treatment Authorization Request |
For members on the Standard Option plan, this form must be
submitted before the ninth visit in a calendar year. Any visit after the
ninth visit requires this form before expiration of authorized visits. For
members with the Basic Option plan, this form must be submitted before start
of treatment or services could be denied. |
|
Only use this form for Regence BlueShield member if FEP is their
primary coverage. |
|
This form is not for any other Regence BlueShield plans. |
|
A separate treatment plan must be submitted for each provider a
member is seeking services from. |
|
Not required for psychological testing or if sole treatment is medication
management (90682). |
|
Verify the type of coverage benefits, eligibility, co-payments,
and deductibles the member has by calling 1 (800) 552-0733. |
|
Treatment plans expire at the end of the calendar year. |
|
| Zung
Self-Rating Depression Scale (PDF) |
The Zung Self-Rating Depression
Scale is a screening tool to identify symptoms of depression
in adults. The ZDS is also useful as an outcome measurement tool to track
a client's progress over time. The first page contains the screening
questions; the second page contains the scoring key. |
|
| Claims &
Billing Forms |
| Form |
Description |
Instructions |
| Billing
Dispute Form (PDF) |
This form is to be used when an office has a billing dispute,
with a specific claim, that was NOT resolved by contacting Customer
Service. The billing dispute process should only be initiated when the
member has no interest in the outcome. |
|
|
Complete all applicable information on the form. |
|
|
Include the name of the person to contact in the office if there
are questions. |
|
|
Include the information listed within the form, on the dispute letter. |
|
|
Fax or mail the billing dispute form and letter to the appropriate
numbers located on the form. |
|
| Corrected
Claim Cover Sheet (PDF) |
This form was designed to facilitate the submission of a
claim. Simply complete the form; attach a copy of the original claim. Submit
to our Seattle post office mailing address.
Using this form will help us quickly identify this as a corrected billing
and forward it on to the appropriate area for reprocessing. |
| |
Complete all applicable fields on the form. |
| |
Make sure you include the claim number that needs correcting. |
| |
Indicate the reason(s) the claim should be corrected (corrected
charges, diagnosis, patient information, etc.) |
| |
Indicate if submitting supporting documentation. |
|
| Hospital
Based Guidelines Form (PDF) |
Use this form when a provider is being added to a hospital-based facility. Regence BlueShield defines Hospital Based Practitioners as, “Practitioners who practice exclusively within a hospital setting, meets our credentialing and contracting criteria and provides care for Regence BlueShield members only as a result of members being directed to the hospital or other inpatient setting." |
| |
Complete the practitioner information. |
| |
Sign the form. |
| |
Include requested copies of State Professional License, DEA Certificate
and proof of insurance. |
| |
Submit to the appropriate address. |
|
| Incident
Report (PDF) |
Regence BlueShield members will receive this form if the condition being
treated requires investigation for third party liability. The member has
45 days to complete, sign, and return the form to Regence BlueShield. If
the member does not return the form within the required time period and
the services are being denied, the providers’ office can bill the
patient for services.
|
| |
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. |
|
| Supporting
Documentation Form (PDF) |
This is a standard cover sheet for submitting medical information
in support of a claim. Using this cover sheet will ensure that documentation
is “attached” to the right claim(s) and will expedite processing.
You may also use this form when you know in advance that Regence BlueShield
requires a report (such as an unlisted procedure code). If you have the
claim number, you may also use this form to submit supporting documentation.
If we have requested supporting documentation the voucher will indicate
when we require additional information. |
| |
Complete all fields on the form. |
| |
Include claim number on form when submitting. |
| |
Do not use for corrected billings or billing disputes. |
| |
Indicate if claim was submitted electronically if applicable. |
|
Complete all member information. |
|
Include the office contact information. |
|
Identify in the comment section, what type of documentation you
are attaching. |
|
| Multiple
Coverage Inquiry (PDF) |
Members will periodically receive this form to notify Regence
BlueShield of any other medical insurance coverage for themselves or any
of their dependents. Members must return the form within the required period
or the charges will be denied as patient responsibility for this claim and
any future claims until the form is submitted. |
| |
Member must complete and sign the form. |
| |
Ask for other insurance information periodically and update your
records. |
| |
Have blank copies in office. If member neglects to complete and
sign, at next visit ask the member to complete and sign so you can
submit. |
|
| Coordination of Benefits (PDF) |
Coordination of Benefits (COB) enables your patients to receive benefits from all health insurance plans they are covered under. Completion of this form will help us process claims correctly. |
| |
Member must complete and sign the form. |
| |
Send completed form to the member's BlueCross and/or Blue Shield plan. |
|
| Native
American Provider Data Form (PDF) |
Use this form when a provider is being added to a tribal
health facility. Regence BlueShield defines Indian Health Practitioners
as: “Providers practicing at a recognized tribal health facility that
meets our contracting criteria and is billing under that facility’s
tax identification number. |
| |
Complete the practitioner information. |
| |
Sign the form. |
| |
Include requested copies of State Professional License and DEA
Certificate. |
| |
Submit to the appropriate address. |
|
| Overpayment/Voucher
Deduction Request (PDF) |
Typically, this form is used when Regence BlueShield has
made an overpayment to your office and you are notifying Regence BlueShield
of the error and asking for a correction.
Online notification:
- Boeing Members
- All other Members
|
| |
Complete all fields on the form. |
| |
Complete the member information. |
| |
Indicate the claim number and reason for deduction(s). |
| |
Your office contact information. |
| |
Make a copy for your records and submit a copy to the appropriate
address listed at the bottom of the form. |
|
| Standard
CHITA Referral Form (PDF) |
This is a standard referral form used by providers statewide.
You can also find this form on the Washington Healthcare Forum. Your office can use this form or your own, when submitting referrals. |
|
|
Complete the referring to and from information. |
|
|
Complete the member’s information. |
|
|
Indicate what action is requested. |
|
|
Check ‘Assume Management’ if applicable. |
| |
List any restrictions or itemizations of procedures if applicable. |
| |
Sign form and submit. |
|
| Notification
of Covering Provider (PDF) |
Use this form when you have providers within your office
or from another location, that you have arrangements with to be ‘on-call’ or
covering for a provider within your office. This form should ONLY be used
if the Tax ID’s are different. Locum Tenens, Temporary Providers,
or PCP’s under the same TAX ID are excluded. By using this form,
our system can be updated to recognize the on call or covering provider
without requiring a referral. |
|
|
Complete the covering provider information. This person(s) will
be on call or covering for you. |
|
|
Complete the information for who is requesting this change. |
|
|
Sign and date the form. |
|
|
Fax or mail the form to the addresses or number(s) on the form.. |
|
| Sample
- Non-covered Services Waiver Form (PDF) |
Complete this form when services requested from a member
are non-covered, excluded, or investigational/ experimental. |
|
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.
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