Premera HMO Core Plus is a forward-thinking plan that offers personalized healthcare with seamless and simplified experiences for providers and members. The Blue-branded HMO product launches January 1, 2023, for Washington residents.
Premera HMO uses the Sherwood HMO network of providers in Pierce, Thurston, and Spokane counties, with more counties coming in 2024.
Read the December 1 Provider News for upcoming training dates for this new 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 if an issue arises.
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 HMO focuses on whole-person care.
A dedicated medical director works closely with primary care providers to optimize referrals and better integrate behavioral health needs. The medical director provides:
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 in 2024 and beyond.
The Sherwood network includes:
The Sherwood network providers includes:
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. View Premera HMO member ID card guide.
Premera uses Availity as the one-stop shop secure website for all Premera HMO provider needs. Availity is a single-source platform for the HMO health plan that providers can use to check member eligibility and benefits, monitor claim status
and submission, and submit referrals and prior authorizations. View Availity Quick Guide for online provider tools.
Availity is a free service. Sign in to
Availity or register and get training. View our Availity
provider FAQ for more details.
Availity offers the quickest way to obtain secure, personalized, easy-to-use information. Providers can:
Availity offers the quickest way to get secure, personalized, easy-to-use information. Providers can verify member eligibility and benefits (including plan effective dates), basic demographic information,
deductible, and benefit limit accumulators.
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.
Sign in to Availity to access the prior authorization tool for Premera Blue Cross HMO Core Plus. The Availity prior authorization tool considers a member’s eligibility and coordination of benefits. The status of these requests can be checked through the
Authorization & Referral inquiry tool or dashboard. If the request is denied, a letter will be mailed to the provider and member.
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.
An HMO member is required to have a referral for specialty services from their PCP who can guide them through the process. The referral tool is available in Availity. There are certain services that are direct access and don't require a referral. Review
the Direct Access Services List before submitting a referral.
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. View Availity Quick Guide for online referral tools.
The code check tool only shows codes used for non-individual plan members (group and associates – includes Premera Blue Cross HMO) and doesn’t provide member-specific information. To access the 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 Authorization & Referrals through Additional Authorizations and Referrals.
The status of a prior authorization or referral requests can be checked through the Auth/Referral inquiry tool or dashboard. If the request is denied, a letter will be mailed to the provider and member.
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.
Claims can be submitted daily, weekly, or monthly. The earlier claims are submitted, the earlier they will be processed. Ideally, claims should be submitted within 60 calendar days of the covered services, but no later than 365 calendar days from the
date of submission. Claims can also be submitted to Premera HMO through Availity Essentials for free.
Sign in to Availity In the Availity menu bar, click Claims & Payments | Claim to submit a professional or facility claim. Select Premera Blue Cross HMO as a payer for professional and facility claims.
To see the status of a claim:
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.
In the Availity menu bar, select Payer Spaces and then select the Premera Blue
Cross HMO logo. Select the Resources or News and Announcements tables to access information specific to Premera Blue Cross HMO.
The PCP roster tool allows a provider to see a list of patients who selected them as their PCP or were assigned to them. A provider can search by TIN, provider, or clinic. The provider can download the roster to see all the information they need to know
about their patient(s).
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.View Provider PCP Roster tool guide.
If a provider is already enrolled in electronic funds transfer (EFT) with Premera Blue Cross plans, no action is
needed to re-enroll through Availity. Premera still processes Availity transactions for EFT requests. However, new providers must enroll for EFT using Availity’s Transaction Enrollment Tool. Watch this how-to demo or view an EFT enrollment help topic.
Note: Use Premera and Affiliates as a health plan payer.
To see a check and 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. Only then can the check information and EOPs be made 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.
Note: If searching by check/EFT number, use a payment reference number if registered for electronic funds transfer. Otherwise, search using the check number. The Premera HMO payer will not display in Availity until we get closer to January
Sign in to Availity or register and get training. View our Availity provider FAQ for
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.
a 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.
A service may require prior authorization. If the
provider doesn’t get a prior authorization, it could result in a payment
penalty to the provider. When a service requires pre-service review, there
isn't a penalty, but Premera will hold the claim and ask for medical
records. Prior authorizations can't be submitted by phone. Prior
authorizations can be submitted through Availity.
The pandemic has brought mental health even further into the spotlight and now it’s become a critical topic. To help our members find the care they need, and to assist providers to ensure that their patients are getting help, we offer a navigation service.
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 from Premera’s contract team as:
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. To that end, HMO members have access to virtual care vendors until clinic-based
providers can offer 24/7 care. Since this care is accessible through MyCare. Sherwood HMO offeres access to the following care providers:
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. Most HMO plans 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.
Core pharmacy programs:
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 Jan 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 infoFor more 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 transactionsSending electronic data interchange (EDI) transactions can help claims process faster and improve cash flow.
Learning CenterFor more information on tools available in Availity.
HMO Reference ManualWhat you need to know on the HMO plan
Training GuidePremera Core Plus Provider Training
HIPAALearn more about our member privacy practices. For HIPAA information specific to providers.
Additional training material, resources, and provider news are available on the Availity secure provider website.
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
Customer service number (non-HMO): 877-342-5258, option 2
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.