Reference Information

  • Federal No Surprises Act: Learn about reducing unexpected medical bills. Get the details

    Here you can learn more about Premera’s patient support programs as well as your responsibilities and requirements as a contracted provider.

  • Learn about submitting credentialing applications, getting review status, and correcting errors.

    Practitioner's Right To Review
    Credentialing File Practitioners have the right to review their credentialing files by notifying the Credentialing Department and requesting an appointment to review their file from outside sources (such as malpractice insurance carriers, state licensing boards). Allow up to seven business days to coordinate schedules. We will not make available references, recommendations, or peer-review protected information.

    Practitioner's Right To Correct Inaccurate Information
    Practitioners have the right to correct inaccurate information. We will notify practitioners in writing if credentialing information obtained from other sources varies from that supplied by the practitioners. Practitioners must explain the discrepancy, may correct any inaccurate information, and may provide any proof available.

    Corrections must be submitted in writing within 30 days of notification and can be submitted by mail, fax, or email:

    Provider Credentialing Department, MS 263
    P.O. Box 327
    Seattle, WA 98111-0327
    Fax: 425-918-4766

    Practitioner's Right To Be Informed of Application Status
    Upon request, practitioners have the right to be informed of their credentialing application status. After the initial credentialing process, practitioners who are in the recredentialing cycle are considered approved unless otherwise notified. If you have specific credentialing questions, call provider customer service at 800-722-4714, option 2, 8 a.m. to 5 p.m., PT.

    To best serve your patients, view the latest formulary updates and prior authorization criteria. You'll find procedures for prescriptions such as medication restrictions, quantity limits, step therapy, and prior authorization or exception request protocols.

    We know that patients can get overwhelmed if diagnosed with a serious illness or health condition, or if they have suffered a serious injury. Premera offers a personalized, one-on-one support program to help your patients manage their condition. This service is available at no additional cost.

    A registered nurse or clinician including social workers, dietitians, and counselors can help your patients:

    • Find resources to support their health and recovery
    • Coordinate care and services for the best treatment
    • Navigate the complex healthcare system

    Our Personal Health Support clinicians can help providers with any delivery system issues, assist their patients in preparing for appointments, and remove any barriers following the provider's treatment recommendations.

    Our Personal Health Support services are available weekdays from 5 a.m. to 8 p.m. and Saturdays 9 a.m. to 5 p.m. Outside these hours, feel free to leave a confidential message and we'll contact you within 24 business hours.

    For more information and to request services, please contact us:

    • Call 888-742-1479 to talk with a personal health support clinician
    • Call 711 (TTY/DD, for deaf and hard of hearing) to consult with a personal health support clinician
    • Email

    Our utilization management program promotes the delivery of appropriate, effective, and efficient care, including medical and pharmacy services and equipment. Here you can learn more about criteria availability, staff access, and our incentive statement.

    Access to medical necessity utilization management
    Physician and nurse reviewers at Premera use written criteria to assist in the determination of medical necessity. The following medical necessity criteria are used and available to contracted providers upon request:

    • Company Medical Policy and Clinical Guidelines (on external website and updated at least annually)
    • McKesson InterQual Clinical Criteria
    • Carelon Medical Benefits Management Guidelines (radiology, cardiac, and radiation oncology)
    • eviCore Healthcare Solutions (physical therapy, massage therapy, occupational therapy)
    • American Society of Addiction Medicine Guidelines for Chemical Dependency
    • Durable Medical Equipment Regional Carriers

    Provider can request criteria related to a specific medical decision for a patient by calling Clinical Review at 877-342-5258, option 3, 8 a.m. – 5 p.m., Monday through Friday. View our complete medical policies and clinical practice guidelines.

    Access to information about the utilization management process
    Providers can contact clinical review staff at 877-342-5258, option 3, during regular business hours, Monday through Friday, 8 a.m. to 5 p.m., Pacific Standard Time, to discuss specific utilization management requirements and procedures or the utilization management process. If calling using a non-toll-free number, the call will be answered by a corporate operator and routed appropriately. Corporate operators are allowed to accept collect calls.

    Ensuring appropriate service and coverage
    We’re committed to covering our members’ care and encourage appropriate use of healthcare services. Providers and Premera staff who make utilization-related decisions must comply with the following policies:

    • Utilization management decisions are based on appropriateness of care and services and existence of coverage.
    • We don't compensate physicians, providers, or other individuals conducting utilization review for denials of coverage or services.
    • We don't provide financial incentives for utilization management decision-makers to encourage decisions that result in under utilization.

    Medical director calls (also called peer-to-peer)
    Providers who receive an adverse decision (denial) related to clinical review for medical necessity or experimental/investigational status can discuss the decision with a physician reviewer. The request may be made by calling 877-835-5672. Often a same-day call back can be arranged.

    Please keep in mind the following:

    • This discussion does not represent an appeal.
    • Requestors must provide the name of the member, member ID, and specific services that were denied.
    • Our clinical review department will arrange for a conference call between the requesting provider and a plan medical director.
    • The phone conversation will not necessarily be with a peer-matched specialty reviewer (specialty matched peer review is part of the Level I appeal process).
    Learn more about specific member rights and responsibilities in our provider manual. This includes things like timely access to specialists and following treatment instructions.
    Want to learn more about Health Equity? Access resources to build knowledge in health equity that provide tools for you to best connect with your patients and community.
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