Partners and Vendors

Artificial intelligence (AI) is rapidly emerging as a transformative technology that promises unprecedented opportunities and efficiencies across all industries, including healthcare. Premera has established a Responsible AI Program that is committedto the development, deployment, and governance of AI applications in a responsible, ethical, legally compliant, transparent, secure, and socially beneficial way while unlocking its transformative potential.

When planning AI innovations in your products or services used by Premera, you must provide advance written notice describing the upcoming changes, with ample time for risk review and confirmation by Premera prior to use. AI implementations should alwayssupport opt-in/opt-out capabilities, as Premera’s requirements may support or restrict the use of AI in certain use cases.

If you’re aware of any possible noncompliance issues, please contact Premera immediately by emailing Compliance@Premera.com or by contacting our externally managed Compliance and Ethics Hotline at mycompliancereport.com or 800-418-1537. Reports may be made anonymously via the Compliance and Ethics Hotline.

If you choose to report anonymously, please include as many details as possible, no matter how small. You’ll receive a case number and are encouraged to check in frequently by calling the Compliance and Ethics Hotline or logging into the website and usingthe case number from your first submission. This ensures we won't need additional information to conduct our investigation.

Visit CMS Program Audits for the most recent audit protocolspublished by the Centers for Medicare and Medicaid Services (CMS). Please usethe relevant sections to ensure your company and any first tier, downstream, orrelated entities can quickly provide CMS with requested documentation in theformats specified. Also make sure your company meets the standards CMS will beauditing. Visit CMS Program Audits for more information.

The MA job aids, developed in coordination with subject matter experts, cover common performance issues found in CMS MA audits of coverage determinations, appeals, and grievances (CDAG) and organization determinations, appeals, and grievances (ODAG) audits.The aids are purposefully short and are not meant to replace CMS regulatory or sub-regulatory guidance. They’re designed to be a quick reference tool for partners’ employees and FDRs to use in their day-to-day work.

Healthcare benefit managers (HCBMs) are required to register with the Washington State Office of the Insurance Commissioner (OIC). HCBMs are defined as persons or entities providing services to, or acting on behalf of, a health carrier that directly orindirectly impact the determination or use of benefits for, or patient access to, healthcare services, drugs, and supplies. HCBMs include specialized benefit types such as pharmacy, radiology, laboratory, and mental health. HCBM services can alsoinclude but are not limited to prior- and pre-authorization of benefits or care; certification of benefits or care; medical necessity determinations; utilization review; benefit determinations; claims processing and repricing; outcome management;payment or authorization of payment to providers and facilities; dispute resolution, grievances, or appeals; provider network management; or disease management.

This registration requirement doesn’t affect member services. If members have questions, they can contact customer service at the phone number on the back of their ID card.

Who are Premera's healthcare benefit managers?

Learn more about vendor guidelines  (PDF document).

Premera Blue Cross is committed to complying with the letter and spirit of all applicable legal and ethical standards with the highest degree of integrity and honesty.

To learn more about our purpose and values visit About Premera.