Premera Blue Cross HMO Resources for Providers

Premera uses Availity as the secure website for all Premera HMO provider needs. Availity is a free, single-source platform to check member eligibility and benefits, monitor claim status and submission, and submit referrals and prior authorizations.

Claims submission

Sign in to Availity and select Claims & Payments | Claim to submit a professional or facility claim. Select Premera Blue Cross HMO as a payer for professional and facility claims.

Claims status

Sign in to Availity and select Claims & Payments | Claim Status to search for a claim by date of service, Member ID or claim number. Select Premera Blue Cross HMO as the payer.

Code check tool

Sign in to Availity, select Payer Spaces, look for the Premera HMO logo, and select the code check tool link under the Resources tab. You can also find the tool in Patient Registration | Authorization & Referrals through Additional Authorizations and Referrals.

Electronic funds transfer for enrollment or cancellation

New providers wanting to enroll for EFT or existing EFT provider wanting to make a change must use Availity’s Transaction Enrollment Tool.

Watch this how-to demo or view an EFT enrollment help topic.

Note: Providers who are already enrolled in EFT with Premera don’t need to re-enroll through Availity.

Eligibility and benefits

Sign in to Availity and select Patient Registration | Eligibility and Benefits Inquiry. Select Premera Blue Cross HMO as the payer and complete the required fields to submit a request.

Explanation of Payments (EOP), Remittance

To view check and explanation of payment (EOP) information that Premera Blue Cross HMO submits to Availity.

• A check needs to be validated for Premera business and dated within the last 30 days.
  • After validation, information for checks and EOPs is visible.
  • EOPs can be accessed through Remittance Viewer, which uses multiple data search points including claim number, check/EFT number, tax ID, NPI, member ID, patient control number, and payer name. View how to find EOPs.

PCP roster tool

Sign in to Availity and select Payer Spaces and then select the Premera Blue Cross HMO logo. Click on the Resources tab and scroll down to the primary care provider (PCP) roster link to access the tool. Access to the tool requires a OneHealthPort user ID and password. View Provider PCP Roster tool guide.

Prior authorization

Sign in to Availity and select Patient Registration | Authorizations & Referrals. On the Authorizations and Referrals page, select Authorization Request. Select Premera Blue Cross HMO as the payer and complete the steps to submit a request.

Referrals

Sign in to Availity and select Patient Registration | Authorizations & Referrals. On the Authorizations & Referrals page, select Referral Request. Select Premera Blue Cross HMO as the payer and complete the steps to complete a request.

Prior authorization and referral status

To check the status of prior authorization and referrals Sign in to Availity and select Patient Registration | Authorizations & Referrals. On the Authorizations and Referrals page, select Auth/Referral Inquiry or Auth/Referral Dashboard and select Premera Blue Cross HMO as a payer.

Resources

For additional resources in the Availity menu bar, select Payer Spaces and then select the Premera Blue Cross HMO logo. Select the Resources or News and Announcements.

Contract information was mailed on or near August 10, 2022.

If you’re part of the Sherwood network, you received an updated contract package for 2023 including:

• A cover letter welcoming you to the network.
• An amendment adding the Premera Blue Cross HMO company to your core agreement.
• A new network attachment adding the HMO network.

If you’re not participating at this time, you received:

• A cover letter stating you're currently not in the network.
• An updated contract amendment adding Premera Blue Cross HMO to your existing core agreement. This allows Premera to expand Premera Blue Cross HMO in the future. You'll be notified in advance if we decide to add you to the network. 

HMO Plus Team - HMO customer service experts

The HMO Plus Team has the skills and autonomy to guide both members and providers through their entire journey while resolving any issues along the way, in real time. This team is focused specifically on HMO and can collaborate directly with providers and respond quickly.

Providers can call provider customer service for HMO at 844-PBC-HMO1 (844-722-4661)
or email hmoplusprovidersupport@premera.com.

The HMO Plus team:

• Manages inbound and outbound member and provider calls
• Answers chats and emails
• Partners with Premera's case management and pharmacy teams to coordinate with PCP offices
• Communicates proactively with members and providers
• Strengthens provider partnerships
• Supports referral processes for member and provider
• Decreases claims rework

Premera Blue Cross HMO focuses on whole-person care.

Dedicated HMO Medical Director

Premera Blue Cross HMO values the relationship with provider groups. For this reason, the HMO has a dedicated medical director with a background in the HMO and PPOs to do the following:

• Ensure long-term collaboration with provider groups for operational and clinical success.
• Share concise actionable data to drive managed care initiatives around patient-centered care.
• Drive interoperability and provider enablement to improve workflow at the front-line level.

Sherwood HMO Network

The HMO network is built from committed providers focused on providing the best care possible at the lowest cost. The network is available in King, Pierce, Spokane, and Thurston counties.

For more information, check out the Sherwood quick reference guide or view the Sherwood HMO provider directory.

ID cards

HMO ID cards serve as a member’s health plan identification and ensure that a member is covered. Check the member’s eligibility and benefits through Availity. The HMO card has unique HMO plan features listed. The Premera Blue Cross HMO logo and the network name Sherwood HMO are both on the front of the ID card. For more information see the Premera ID Card Guide.

View all the forms you need for Premera HMO.

The PCP is the member's main point of contact for care. Members can choose from different provider specialties for their PCP, including:

• Family medicine
• Geriatric medicine
• General practice
• Gynecology
• Internal medicine
• Adolescent medicine
• Naturopathy
• Pediatrics

Note: PCP provider types can be a doctor of medicine (MD), a doctor of osteopathic medicine (DO), an advanced register nurse practitioner (ARNP), a nurse practitioner (NP), or a physician assistant (PA).

HMO members and their dependents can choose an in-network primary care provider (PCP) using the Find Care tool. They can use the Find Care tool to change their PCP at any time. Users will land on the PCP page after clicking the PCP notification call to action. From here, users may “Change PCP” or “Go to PCP details.”

HMO members and their dependents will need to select a primary care provider (PCP). If they don’t select a PCP, Premera will suggest a PCP for them. The member-PCP relationship is an important part of the Premera HMO Core Plus plan because the PCP will guide the member and their dependents through their healthcare needs.

Check to see if a provider is in the Sherwood HMO network.

How does Premera Blue Cross HMO choose a PCP for a member?

The process starts with a review of a member’s claims history to identify if the member has received care from a particular PCP in the past. If the review does not suggest an existing PCP relationship, a PCP will be suggested based on:

• Location (nearest to member’s home address)
• Type of provider
• Specialty

Note: Suggested PCPs are in the Sherwood HMO network and are currently accepting new patients. View Guide to HMO Core Plus member PCP search and select.

Sherwood HMO Network Provider Directory

Providers and members have access to the Sherwood HMO Network provider directory to help them pick the right provider for their needs. 

Changing/Selecting a PCP

If a member chooses to change or manually search for a PCP, they will be directed to the Changing/Selecting a page.

Matchmaker^TM for Behavioral Health

Behavioral health is a key part of whole person care. Premera has a navigation service to help members find the care they need, and to assist providers find care for their patients. With one phone call to our HMO Plus Team number (844-PBC-HMO1 or 844-722-4661), Premera can help a member find a provider that meets their needs and is accepting patients.

Urgent and emergency care

Our HMO is an in-network offering only. However, when an urgent situation arises an HMO member can utilize urgent care and emergency care anywhere in the United States. Emergency care is explained as the following:

• “Examination and treatment as required to stabilize a patient to the extent the examination and treatment are within the capability of the staff and facilities available at a hospital.
• "Stabilize means to provide medical, mental health, or substance use disorder treatment necessary to ensure that, within reasonable medical probability, no material deterioration of an emergency condition is likely to occur during or to result from the transfer of the patient from a facility; and for a pregnant member in active labor, to perform the delivery.”

24/7 Virtual care

Premera believes in helping members at all points of their care journey. There are partnerships in place with many best-in-class organizations to help members live healthier lives. HMO members have access to virtual care providers 24/7 through the Premera app. Virtual care providers are as follows:

• 98point6
• 24-Hour NurseLine
• Doctor On Demand
• Boulder Care
• Talkspace
• Livongo (for SEBB only)

Enhanced digital experience

To give HMO members more control over the management of their healthcare, the HMO program provides digital tools like:

• PCP Selection
• Referral and authorization notifications
• Virtual visits

Pharmacy Services

HMO pharmacy services include dedicated support from the HMO Plus Team and proactive outreach focusing on providing the right care at the right time. Premera pharmacists are available for clinical consultations with members and providers to answer any medication questions they may have, which may include:

• Reviewing medications and providing education or answering drug information questions
• Discussing medication side effects, interactions, and possible alternatives
• Reviewing benefit information and identifying savings opportunities
• Helping support medication management addressing barriers to optimal use

HMO members have access to the National 2.0 network through Express Scripts (ESI), providing many options for patients to fulfill their medication needs. Most Premera HMO plans (SEBB not included) will require the use of exclusive home delivery using the Express Scripts mail-order pharmacy for maintenance medications it’s designed to be a cost saving strategy for members. For more information: https://www.premera.com/wa/provider/pharmacy/understanding-your-benefits/about-pharmacy/

Essentials Formulary

• The HMO formulary is organized into 4-tiers that drive the members cost share: preferred generics (tier 1), preferred brand (tier 2), preferred specialty (tier 3), and non-preferred drugs (tier 4).  In addition, some drugs may also be excluded from coverage.  The full drug list can be found here.
• All drugs are reviewed and placed into a formulary tier by the Premera Pharmacy & Therapeutics (P&T) Committee based on clinical efficacy, safety, alternatives, and cost effectiveness.
• The Premera P&T Committee is an independent set of experts composed of leading physicians, pharmacists, health economists, a bioethicist, and a member representative.

Dental care

HMO plans cover certain medical services that are provided by a dental provider, which are listed as covered under the medical plan, but dental services are offered separately from HMO.

Beginning January 1, 2023, with the HMO medical product, an employer can select a Premera branded dental plan. If the employer selects a dental plan, their employees will have dental coverage. If an employer doesn’t select a Premera Blue Cross dental plan, then the member will not have dental coverage through Premera.

Digital care management (powered by Wellframe*)

Our digital care management program is designed to meet members where they are—on their terms and timeline. This program connects members with their care manager through a secure digital chat in the Wellframe app.

It also provides:

• Digital programs curated for members' needs
• Care transition management​
• Behavioral health coordination​
• Condition management​
• Lifestyle management

Refer a member to Premera’s digital management program:

• Email: case.management@premera.com
• Contact a Case Manager: 888-742-1479

*Wellframe is an independent company that provides digital support services on behalf of Premera Blue Cross HMO.

An HMO member is required to have a referral for specialty services from their PCP for a specialist or PCP. The referral tool is available in Availity to submit a request for specialty services.

There are certain services that are direct access and don't require a referral. View direct access services list.

If an approved referral is not provided and a member chooses to receive services from providers or facilities, those services will not be covered under this plan. The member will be responsible for 100% of the cost for these services and any amount will not apply to their out-of-pocket maximum, except services required by federal or state law. View Availity Referral Tool Quick Reference Guide.

Refer to the HMO Plus team customer service experts for referral support or search Find Care for in-network providers

Prior Authorizations

A service may require prior authorization and/or medical necessity review (unlisted codes, cosmetic procedures, investigative procedures, etc. are examples that may not require prior authorization but may be reviewed for medical necessity). If the provider doesn’t get a prior authorization, it could result in a payment penalty to the provider. When a service does not require prior authorization but does require a medical necessity review, there isn't a penalty, but Premera will hold the claim and request medical records. Prior authorizations can be submitted through Availity or fax to 888-704-2091. Prior authorizations can't be submitted by phone. Premera typically responds to electronically submitted requests within 1-2 days, but it can take up to 3 days. Check your Auth/Referral dashboard in Availity after submitting the authorization request for status. Note: Most requests will be auto approved if both the requesting and servicing provider are Sherwood HMO network providers.

Reference info
Get information on Premera’s patient support programs as well as your responsibilities and requirements as a contracted provider.

Provider News
Keep with the latest news. Sign up to receive Premera news by email

Health management
Collaborative programs that support the patient-doctor relationship.

Electronic transactions
Learn how sending electronic data interchange (EDI) transactions can help claims process faster and improve cash flow.

Learning Center
Get more information on tools available in Availity.

HMO Reference Manual
Find everything you need to know for the HMO plan.

Training Guide
Get Premera Core Plus provider training.

Quality and Coding Tools
Quality measures tip sheets and documentation and coding guides.

Tip Sheets Diagnostic HMO
Tip Sheets Quality and Coding Tools HMO
Tip Sheets Data Submissions HMO

HIPAA
Learn more about our member privacy practices. For HIPAA information specific to providers.

Premera training deck (December 7, 2022)

Availity training: Available through Help & Training > Get Trained in the upper right of the page.

Premera HMO member education resources

• How HMOs Work
• Referrals

Providers and members have access to the Sherwood HMO Network provider directory to help them pick the right provider for their needs.