Premera Blue Cross HMO Resources for Providers

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 if an issue arises.

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
• Coordinates with case management and pharmacy
• Communicates proactively with members and providers
• Strengthens provider partnerships
• Supports referral processes
• Moves non-clinical work from medical management to a more appropriate venue
• Decreases claims rework

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. 

Premera HMO focuses on whole-person care.

Dedicated Premera HMO Medical Director

A dedicated medical director works closely with primary care providers to optimize referrals and better integrate behavioral health needs. The medical director provides:

• Long-term collaboration with provider groups for operation success
• Data to drive managed care initiatives to keep members healthy
• Ongoing reviews of population health data for impactful initiatives
• Member-centric programs and primary care prioritization

Sherwood HMO Network

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:

• 15 hospitals
• 66 urgent care clinics
• More than 1,900 PCPs
• 11,000 specialists

The Sherwood network providers includes:

• MultiCare Health System
• MultiCare Indigo Urgent Care
• MultiCare Rockwood Clinics
• MultiCare Capital Medical Center
• Rockwood Inland Eye Surgery Center
• NAVOS
• Wellfound Behavioral Health Hospital
• Greater Lakes Mental Healthcare
• Mary Bridge Children’s Hospital
• Seattle Children’s Hospital
• Kinwell Clinics - primary care for Premera
• HMO Core Plus members

For more information, view Sherwood Provider Directory quick reference guide.

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. 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:

• Verify member eligibility and benefits (including plan effective dates)
• Verify deductibles copay and coinsurance
• Verify benefit limit accumulators
• Check claim status
• Submit a professional or facility claim (free service through the Premera HMO payer)
• Submit and check the status of a prior authorization and referral
• View check and explanation of payment (EOP) information
• Register for electronic funds transfer for enrollment or cancellation using Premera and Affiliates as a health plan payer

Eligibility and benefits

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.

Prior authorization

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.

Referrals

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.

Code check tool

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.

Check prior authorization and referral status

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 submission

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.

Claims status

To see the status of a claim:

• Online: The best way to check claim status is to sign in to Availity. Information is available 24 hours per day, seven days per week.
• Customer service: If you don't have online access, contact customer service at 844-722-4661, or call the phone number on the back of the member's ID card.
• Interactive voice response (IVR): Available 24/7. IVR provides claims information.

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.

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 tables to access information specific to Premera Blue Cross HMO.  

Provider online PCP roster tool

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.

Electronic funds transfer for enrollment or cancellation

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.

Remittance and Explanation of Payments (EOP)

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 1, 2023.

Sign in to Availity or register and get training. View our Availity provider FAQ for more details.

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
• Gender

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.

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 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.

Prior Authorizations

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.

Behavioral Health Navigator

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.

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 from Premera’s contract team as:

• “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.”
• “Ambulance transport is needed in support of the services above.”

Urgent care comes to the member with Dispatch Health

Members can avoid wait times for urgent care with Dispatch Health, a provider group contracted with Premera.  

• At the cost of a co-pay, members can have Dispatch Health come to their home or work.
• They provide on-demand, qualified, acute care to keep patients out of the hospital seven days per week, 8 a.m. to 10 p.m. Pacific Time.
• A provider, case manager or patient can request care via phone or web.
• To eliminate barriers to getting care and the need for transportation, Dispatch Health sends a care team directly to a patient’s home.
• Once on the scene the care team can provide 60-70% of care available in the ER
• Dispatch Health  collaborates closely with the patient’s primary care provider for close follow up if needed.

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. 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:

• 98point6
• 24-Hour Nurse line
• Doctor On Demand
• Workit Health
• Boulder Care
• Talkspace
• Livongo

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
• Digital care management
• 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. 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:

• Low copays for Tier 1 and 2 drugs
• Dedicated support to members pharmacy needs

Formulary

• Allows for the most restrictive and high-value options for medications through medication exclusions and unique tiering options
• Exclusions: reduce cost of high-cost, low-value drugs, and steer members to lower cost alternatives in select classes
• Tier 4 has non-preferred generics, brand, and specialty medications to reduce use of high-cost, low-value medications

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 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.

Digital care management (powered by Well frame)

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:

• Digital programs curated for a digital user with case management support
• Care transition management​
• Behavioral health coordination​
• Condition management​
• Lifestyle management

To refer a member to Premera’s case and digital management service:

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

Reference info
For more 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
Sending electronic data interchange (EDI) transactions can help claims process faster and improve cash flow.

Learning Center
For more information on tools available in Availity.  

HMO Reference Manual
What you need to know on the HMO plan

Training Guide
Premera Core Plus Provider Training

HIPAA
Learn 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.

• Premera training deck (December 7, 2022)
• Availity training: Available through Help & Training > Get Trained in the upper right of the page.
• Provider News: Sign up for email notifications. Available on the Premera Blue Cross HMO Payer Space in the News and Announcements tab.
• Learning Center: Reminder - Premera secure portal tools are now available through Availity.
• Premera HMO member education resources
  • How HMOs Work
  • Referrals