HMO Core Plus is a forward-thinking plan that offers personalized healthcare with seamless and simplified experiences for providers and members.
The HMO Core Plus plan uses the Sherwood HMO network of providers in Pierce, Thurston, and Spokane counties. Beginning January 1, 2024, the HMO Core Plus plan will expand into King County.
Read Provider News for information and updates on the HMO Core Plus plan. If you have any questions, contact
your network executive or email email@example.com.
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 firstname.lastname@example.org.
The HMO Plus team:
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:
If you’re not participating at this time, you received:
Premera Blue Cross HMO focuses on whole-person care.
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:
The HMO network is built from committed providers who are focused on providing the best care possible at the lowest cost. The network is available in Pierce,
Thurston, and Spokane counties, with further expansion into King County beginning January 1, 2024.
For more information, view Sherwood Provider Directory quick reference guide.
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.
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.
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.
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.
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.
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.
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.
To view check and explanation of payment (EOP) information that Premera Blue Cross HMO submits to Availity.
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.
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.
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.
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.
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.
The PCP is the member's main point of contact for care. Members can choose from different provider specialties for their PCP, including:
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.
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:
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.
Providers and members have access to the Sherwood HMO Network provider directory to help them pick the right provider for their needs.
If a member chooses to change or manually search for a PCP, they will be directed to the Changing/Selecting a page.
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.
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
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 requests within 1-2 days, but it can take up to 5 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.
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.
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:
Members can avoid wait times for urgent care with Dispatch Health, a provider group contracted with Premera.
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 MyCare app. Virtual care providers are as follows:
To give HMO members more control over the management of their healthcare, the HMO program provides digital tools like:
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:
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/
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.
Our digital care management service meets members where they are in the mode and cadence they prefer. The service offering digital text and chat functionality between a member and their care manager. It also provides:
To refer a member to Premera’s case and digital management service:
Reference infoGet information on Premera’s patient support programs as well as your responsibilities and requirements as a contracted provider.
Provider NewsKeep with the latest news. Sign up to receive Premera news by email
Health managementCollaborative programs that support the patient-doctor relationship.
Electronic transactionsLearn how sending electronic data interchange (EDI) transactions can help claims process faster and improve cash flow.
Learning CenterGet more information on tools available in Availity.
HMO Reference ManualFind everything you need to know for the HMO plan.
Training GuideGet Premera Core Plus provider training.
Quality and Coding ToolsQuality measures tip sheets and documentation and coding guides.
Tip Sheets Diagnostic HMOTip Sheets Quality and Coding Tools HMOTip Sheets Virtual HMO
HIPAALearn more about our member privacy practices. For HIPAA information specific to providers.
deck (December 7, 2022)
Availity training: Available through Help & Training > Get Trained in the upper right of the page.
Premera HMO member education resources
View all the forms you need for Premera HMO.
HMO Plus Team - HMO customer
service experts for providers (includes clinical review):844-PBC-HMO1 (844-722-4661) (TTY: 711)
HMO Plus Team - customer
service email: email@example.com
Claims address: P.O. Box 91059, Seattle WA 98111-9159
Customer service number (non-HMO): 877-342-5258, option 2
*Pending OIC filing. The anticipated filing date
is the end of August 2023.
Pharmacy services: 888-261-1756
Case management: 888-742-1479, Monday - Friday 8:00 a.m. to 7:00 p.m. and Saturdays 9:00 a.m. to 1:00 p.m.