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Authorized Representative Form
Member Appeal Filing Form
Medical Preauthorization Forms
Nominate a Provider Form
Records Release Consent Form
Release Health Information … more
1 - 10 of 61 results
General Forms
Authorized Representative Form
Member Appeal Filing Form
Medical Preauthorization Forms
Nominate a Provider Form
Records Release Consent Form
Release Health Information … more
Coordination of Benefits / Direct Claim Form
Submit Direct Claim Electronically
Express Scripts Mail Order Form
Diabetes Savings Program Form
Electronic Trading Partner Agreement (ETPA) form must be executed by the provider before they are allowed access to the PEHP Provider secure website which provides member eligibility, claims … more
If a Provider believes PEHP has made an error in processing a claim or making a decision, the Provider may appeal as follows:
First-Level Appeal - A written appeal must be completed in full, … more
If a Provider believes PEHP has made an error in processing a claim or making a decision, the Provider may appeal as follows:
First-Level Appeal - A written appeal must be completed in full, … more
Attention: Submit Claims Electronically for Faster Payment
PEHP is currently processing electronically submitted dental claims in as little as 10 days. To encourage all dentists to transition to … more
Prohibition Against Balance Billing
Contract Providers may only collect from a member that member’s applicable cost-sharing responsibility for a covered service. Contract Providers may not collect … more
For claims to pay, you must be set up in PEHP’s system and you must submit your claims electronically.
To be set up in our system, complete the Provider Account Information form and return it via … more
For claims to pay, you must be set up in PEHP’s system and you must submit your claims electronically.
To be set up in our system, complete the Provider Account Information form and return it via … more
2025 Fee Schedule Notice
Update Demographics (contact information, addresses or email), Report new portal account creation error, or Adding non-contracted provider for claim submission
Please … more