For providers (change)

Attention!

You are about to leave regence.com and enter another website that is not affiliated with or licensed by the Blue Cross Blue Shield Association.

Request for raw data

Please complete all fields of this form to ensure your request for data is processed quickly and accurately.

Your details

Provider name*

Requester name*

Requester phone*

Requester email address*

Research*

837 Claim

835 ERA

835 ERA Check number

Claim type*

Institutional

Professional

NPI*

Tax ID*

Claim submission date*

MM/dd/yyyy

Member number (including prefix)*

Dollar amount/Total charge $*

Date of service*

MM/dd/yyyy

Attention!

You are about to leave our Medicare website.