Premera BCBS Form 004674 2014-2025 free printable template

ORGANIZATION/FACILITY CREDENTIALING/CREDENTIALING APPLICATION CURRENT COPIES OF DOCUMENTS TO BE SUPPLIED WITH COMPLETED APPLICATION INCLUDES: All accreditation certificates State license (as applicable)

How to fill out Premera BCBS Form 004674

How to fill out Premera BCBS Form 004674

1. Begin by gathering all necessary personal information, including your name, address, and contact details.
2. Fill out the member ID and policy number accurately in the designated fields.
3. Indicate the type of service you are requesting by selecting the appropriate option from the list provided.
4. Detail the dates of service or treatment and the provider's information, including their name and contact details.
5. Clearly outline the reasons for the request, using concise and relevant information.
6. Attach any required documentation or additional forms that support your request.
7. Review the form thoroughly to ensure all information is correct and complete.
8. Sign and date the form as required before submission.

Who needs Premera BCBS Form 004674?

1. Individuals who are seeking reimbursement for medical services or procedures covered by their Premera BCBS insurance plan.
2. Providers who need to submit claims for services rendered to patients covered under Premera BCBS.

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What is Premera BCBS Form 004674?

Premera BCBS Form 004674 is a specific form used for submitting information related to insurance claims and provider services to Premera Blue Cross Blue Shield.

Who is required to file Premera BCBS Form 004674?

Healthcare providers who are billing for services rendered to patients covered by Premera Blue Cross Blue Shield are required to file Form 004674.

How to fill out Premera BCBS Form 004674?

To fill out Premera BCBS Form 004674, complete all required fields including patient information, provider details, service codes, and any other pertinent information as instructed on the form.

What is the purpose of Premera BCBS Form 004674?

The purpose of Premera BCBS Form 004674 is to facilitate the claims submission process for healthcare services provided to members, ensuring accurate billing and reimbursements.

What information must be reported on Premera BCBS Form 004674?

The information that must be reported on Premera BCBS Form 004674 includes patient identification, provider details, services rendered, applicable diagnosis codes, and any other relevant billing information.