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Regence uniform medical claim form 2026

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The document is a Medical Claim Form for submitting reimbursement requests for services received from non-network providers under the PEBB and SEBB Uniform Medical Plans. It outlines the necessary steps to complete the form, including attaching itemized bills, retaining copies, and submitting the form to Regence BlueShield. The form requires personal information about the patient and subscriber, details on other insurance coverage, and certifies that all provided information is accurate.

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Click ‘Get Form’ to open the regence uniform medical claim form in the editor.
Begin by filling out the patient’s information, including their last name, first name, date of birth, and sex. Ensure accuracy as this information is crucial for processing your claim.
Next, provide details about the subscriber, including their last name, first name, group name, and group number. This helps link the claim to the correct insurance policy.
In the 'Other Insurance Information' section, indicate if you or any family members have additional coverage. If yes, complete the relevant fields regarding other insurance plans.
Attach itemized bills that include necessary details such as diagnosis and procedure codes. Use our platform's upload feature to easily attach these documents.
Finally, sign and date the form at the bottom before submitting it either by mail or fax as indicated on the form.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (208 Votes)
2020	4.4 Satisfied (60 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the medical claim form?

Regence participating providers and facilities and any non-participating provider or facility located in our service area must submit their claims electronically.

What is Regence Uniform medical Plan?

In simpler terms, a medical claim form is a formal written request that a healthcare provider submits to an insurance company, Medicare or Medicaid, or another affiliated entity seeking compensation for the healthcare services provided to a patient.

Does Novitas accept paper claims?

Listed below are the exceptions Novitas Solutions can accept as a hardcopy claim submission. All other claims must be submitted via Direct Date Entry (DDE) or electronically. Note: ASCA prohibits payment of paper submitted claims except in limited situations such as small providers, etc.

Does Regence accept paper claims?

Your UMP health plan is a valuable benefit that includes medical and prescription drug coverage to help you stay healthy and pay for the cost of an illness or injury. When you see a network provider for covered preventive care servicesincluding routine annual physical exams and certain immunizationsyou pay $0.

What is the timely filing limit for Regence Blue Shield of Washington claims?

Please complete a separate form for each family member. The time limit for filing claims is one year from the date of service/purchase.

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What is the difference between paper claims and electronic claims?

Slow Processing: Paper claims take longer to process than electronic claims due to manual handling, mailing times, and potential errors in handwritten forms. Higher Costs: Printing, postage, and manual processing can incur higher costs over time, especially for large volumes of claims.

Are Regence and Blue Shield the same?

Regence is the name given to Blue Cross and Blue Shield plans in four northwestern states. Serving 2.2 million members, Regence offers health insurance plans under the following names.