Premera Blue Cross HMO Resources for Providers

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    Premera Blue Cross HMO is available January 1, 2023

    Premera Blue Cross HMO is an innovative, new health plan for Washington state residents, available January 1, 2023. Premera HMO gives members an affordable, Blue-branded HMO product option.

    Premera HMO uses the Sherwood network of providers in Pierce, Thurston, and Spokane counties, with more counties coming in the future.

    Watch Provider News for upcoming training dates for this new plan. If you have any questions, contact your network executive, call 877-342-5258, option 4, or email provider.relationswest@premera.com.

  • 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 are 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 will be notified in advance if we decide to add you to the network. 

    Premera HMO focuses on whole-person care.

    Care guided by primary care providers (PCPs): Members select a PCP in their network who serves as their “quarterback of care” to guide them and their dependents.

    PCP Selection: Premera HMO members select a PCP in the Sherwood network. Members can select any in-network PCP who best fits their needs.

    Referrals:  A PCP is a member’s quarterback of care and can refer members to a specialist when needed. PCPs will also receive a list of members assigned to them.

    Dedicated Premera HMO Medical Director: A dedicated medical director guides Premera HMO members through provider partnerships, collaboration, and need-based clinical program development.

    Premera has implemented Availity as the one-stop shop secure websites for the HMO plan needs. Availity is a single-source platform for multiple health plans for checking member eligibility and benefits, submitting prior authorizations and claims, and more. Premera is partnering with Availity because of its local and national presence and capability to deliver functionality beyond our existing secure provider portal. Availity will serve both in-area and out-of-area providers through a comprehensive, multi-payer platform that enables ease and efficiency through self-service. Availity is a free service.

    The secure tools in Availity for the Premier HMO payer plan will include:

    • Eligibility & benefits
    • Prior authorization
    • Referrals
    • Check prior authorization status
    • Claims & payments
    • Electronic funds transfer for enrollment or cancellation

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

    Note: The Premera HMO payer will not display in Availity until we get closer to January 1, 2023.

    Premera HMO members can choose from several different kinds of providers as their PCP, including those that specialize in:

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

    Your PCP can also be a:

    • Nurse practitioner
    • Physician assistant

    PCP referrals are required for specialty services. The following direct access services, however, do not require a referral:

    Alternative medicine

    • Acupuncture
    • Chiropractic care
    • Naturopathic services
    • Outpatient physical, occupational and speech therapy, massage therapy (benefit limits apply)
    • Spinal manipulation

    Hospital-based services

    • Anesthesia (regardless of location)
    • Blood bank services

    Preventive services

    Find preventive services here

    Other services

    • Ambulance/air ambulance (Emergent/Urgent care only)
    • Ancillary services (X-ray, lab, pathology)
    • DME purchases/rentals/supplies (some supplies require authorization)
    • Emergency services/Urgent care
    • Eye exam (adult and pediatric)
    • Family planning services
    • Hearing hardware
    • Inpatient hospital ancillary professional fees
    • Male & female sterilization
    • Newborn care (up to 31 days)
    • Pediatric dental
    • Obstetric care
    • Outpatient behavioral health (includes hypnosis)
    • Urgent care centers
    • Vision hardware (including contacts)