Forms for Regence BlueShield of Idaho Members

Authorization Forms
Appeals and Grievance Form
Medicare Advantage and most ASO (Alternate Funded Groups) products not applicable


English (Fillable PDF)
Spanish (Fillable PDF)
Use this form to request an appeal to a coverage determination or to file a complaint/grievance with us.
Authorization to Disclose Protected Health Information

English (PDF)
Spanish (PDF)
Authorization for Regence BlueShield of Idaho to disclose health information to a designated party for a specific purpose.
Automatic Payment Form (PDF) Complete the Automatic Payment Form to authorize your personal bank to transfer funds to Regence BlueShield of Idaho for payment of monthly premiums. Withdrawals of funds occur between the 5th and 7th of each month.

Please mail form to:
Regence BlueShield of Idaho
Attn: Individual Membership
PO Box 1106
Lewiston ID 83501
Proxy Notice (PDF) Complete the Proxy Notice form if you'd like the Regence BlueShield of Idaho Board of Directors to serve as your voting representation at annual meetings.
Statement of Accidental Death Form (PDF) Use this form upon the accidental death of a contract holder or covered dependent.
Coordination of Benefits/Multiple Coverage Inquiry

Coordination of Benefits (PDF)

Coordination of Benefits (COB) is a provision that allows family members covered by two or more health plans to receive up to 100% coverage for healthcare services.

Mail form to:
PO Box 1271, MS-4L
Portland, OR 97207-9861

or FAX: 1 (888) 661-2850
Coordination of Benefits FAQ Some common questions and answers about this form.
Claim Forms
Member Reimbursement Claim Form (PDF) Use this form to submit claims for covered services (medical, dental, vision or prescription medications) that require you to pay out-of-pocket and submit for reimbursement.

You may mail, email or fax your reimbursement form and receipts to us.
Email: CPSS_CSINFO@Regence.com
Fax: 888-606-6582
International Claims
(BlueCard Worldwide)
Go to BlueCard Worldwide and find the International Claim Form you need at the bottom of the page to submit for benefits for covered services received outside the U.S., Puerto Rico, Jamaica and the U.S. Virgin Islands.
Incident Report
Incident Report (PDF)

English (PDF)
Spanish (PDF)
Download and mail or fax the Incident Report. Please return the complete form.


By Mail:
PO Box 12625 MS S1C
Salem, OR 97309

By Fax: 1 (888) 891-0771
Incident Report FAQ Some common questions and answers about this form.
Plan Enrollment and Change Forms
Adding a Newborn to Your Policy (PDF) Use this form to add a newborn to your policy.
Affidavit of Domestic Partnership (PDF) Employees and their domestic partners applying for coverage should complete this form.
Affidavit of Qualifying Incapacitated Dependent Eligibility (PDF) Use this form to certify that an eligible dependent child is incapacitated due to medical disability, developmental disability or mental disorder.
Retiree Insurance Benefits Request Form (PDF) Please complete this form when planning to retire but still requesting insurance coverage from your group.
Special Beginnings enrollment questionnaire and prenatal book order form (PDF) If you are interested in our Special Beginnings Maternity Management program, please complete the enrollment questionnaire and prenatal book order form. After submitting the completed forms, the member will receive tailored educational materials. Please fax the completed enrollment form and prenatal book form to:

Special Beginnings
Regence BlueShield of Idaho
P.O. Box 1106
MS LA1W
Lewiston, ID 83501
Transfer and Rate Review (PDF) Complete the Transfer and Rate Review to have your health factor reviewed.
Prescription Medication Forms
Prescription mail-order forms can now be found on the RegenceRx Member Web site.
Incident Report FAQ
Questions Answers
What is subrogation and why does Regence need accident information? Your health contract contains a subrogation provision that allows us to recoup claims payments we have made for injuries or illnesses caused by a third party. This means that when Regence pays medical bills for an injury or illness that has been caused by a third party, we will seek reimbursement of those medical bills from the third party, their insurance company, and/or your insurance company.
How does subrogation help me? Subrogation can help control premium costs paid by you and/or your employer. Subrogation can also help to restore your lifetime maximum benefit amounts.
What if I was injured on the job? Your health contract excludes payment of claims for work-related injuries and illnesses. This means we will not provide benefits if workers' compensation laws cover, provide or pay for services, supplies or treatment of an accident or illness. In addition, if a workers' compensation claim settlement (including a disputed settlement award) is received, we will not provide medical benefits for the injury or illness. If your claim is denied, please send us a copy of the denial so we can process your claim.
What about other types of injuries or illnesses? We are requesting information in order to determine if another entity or individual may be responsible for your injury or illness. Necessary information is supplied through an incident report. Examples of the types of accidents or illnesses that may have third party liability include motor vehicle accidents, work-related injuries and illnesses, injuries on another person's property (such as falling in a grocery story), defective products or machinery, and food poisoning.
What if I have an attorney involved? We need the name, address and phone number of any attorney hired to represent you.
Do I still need to complete the form if the claim isn't accident-related another party's fault? Yes. If we receive your information stating there is no third party liability for your injury or illness, we will note the information in our system and expedite processing of related claims.
What is a Declaration page and when do I need to send it to you? A declaration page is the page of your automobile policy that states the vehicle(s) insured on the policy and what coverage you have elected. We will need a copy of this whenever you have been involved in an automobile accident. We need this whether or not the accident was your fault. Although your declaration page may look different, here is an example of what the page may look like:

1999 Honda Civic
Limits
Liability $50,000
Personal Injury Protection $15,000
Medical Payments $5,000
Bodily Injury to Others $50,000
Collision $50,000
UM/UIM $50,000
Coordination of Benefits FAQ
Questions Answers
What is Coordination of Benefits and how does it help me? Coordination of Benefits (COB) is a provision that allows family members covered by two or more health plans to receive up to 100% coverage for healthcare services.
Why does Regence need this information? Coordination of Benefits helps ensure that members covered by more than one plan will receive the benefits they are entitled to while avoiding overpayment by either plan. Coordination of benefits is one of the ways we work to keep premiums at a minimum. We depend upon your help in order for us to process your claims correctly and appreciate your prompt and accurate reply.
How does Coordination of Benefits work? One plan is considered to be the primary carrier and the other is considered to be the secondary carrier. The primary carrier covers the major portion of the bill according to plan allowances, and the secondary carrier covers any remaining allowable expense. The COB provisions of your policy or plan determine which plan is primary.
What's the fastest way to get claims processed? When you check in with your provider of health services, always present both identification cards to them and let them know to bill the Primary plan first. Your provider should not bill the Secondary plan until your provider has received an explanation of benefits from the Primary plan.
How does Regence determine which health plan is primary when I'm the employee, member, or subscriber under both policies? • Regence uses industry standards that were created by the National Association of Insurance Commissioners (NAIC).

• If a plan does not contain a COB provision, that plan is Primary and will pay first.

• The plan that covers you as an employee, member or subscriber is primary over the plan that covers you as a dependent.

• The plan that covers you as an active employee (not as a laid-off employee or retiree) is primary over the plan that covers you as a laid-off employee or retiree.

• If you are covered as an employee, member or subscriber under more than one plan, but are covered under state or federal continuation (COBRA) under one of the plans, then:
   - The plan covering you as an employee, member or subscriber is primary over the plan covering you under state or federal continuation (COBRA).

• If you are covered as an employee, member or subscriber under more than one plan, and none of the above rules apply, then:
   - The plan that has been in effect the longest is primary, back to your original effective date under your employer group, whether or not the insurance company has changed over the course of coverage.
How does Regence determine which health plan is primary for dependent children of parents not separated or divorced? • Regence uses industry standards that were created by the National Association of Insurance Commissioners (NAIC).

• If a plan does not contain a COB provision, that plan is Primary and will pay first.

• If dependent children are covered under both plans, the plan covering the parent whose birthday is earlier in the calendar year will be the Primary plan for the children. If both parents have the same birthday, the plan that has been in effect longer will be Primary. Note: Birthday refers only to the month and day in a calendar year, not the year in which the person was born.
How does Regence determine which health plan is primary for dependent children of separated or divorced parents? • Regence uses industry standards that were created by the National Association of Insurance Commissioners (NAIC).

• If a plan does not contain a COB provision, that plan is Primary and will pay first.

•  If your child is covered by more than one plan and you are separated or divorced from the other parent, the plans must pay in the following order:
   - First, the plan of the parent with custody of the child;
   - Then, the plan of the spouse of the parent with custody of the child;
   - Finally, the plan of the parent not having custody of the child. However, if terms of a court decree state that one parent is responsible for the health care expenses of the child, and the insurance company has been advised of the responsibility, that plan is primary carrier over the plan of the other parent.

• If parents have joint custody, then the birthday rule applies in this situation. The plan covering the parent whose birthday is earlier in the calendar year will be the Primary plan for the child. If both parents have the same birthday, the plan that has been in effect longer will be Primary. Note: Birthday refers only to the month and day in a calendar year, not the year in which the person was born.
What should I do if there's a change in coverage for myself or a family member? If you or a family member obtains additional coverage or loses coverage under a health plan, please notify us immediately. We depend upon your help in order for us to process your claims correctly.