Individual Plan Administration Transition: Provider FAQ

  • Use these questions and answers to understand what is changing for individual plans beginning January 1, 2027, and how those changes may affect administrative activities such as Availity access, claims, prior authorization, payments, appeals, and contact information.

  • Starting January 1, 2027, Premera will be changing how we administer its Individual plans, which are currently managed by Evolent. This change will affect how providers and members interact with us and manage key administrative activities.

    Premera uses Availity Essentials for plan administration. Sign in to Availity.

    Beginning January 1, 2027, providers will use the same Availity payer for individual members that they already use for non-individual Premera members: Premera Blue Cross.

    If you are an active user in Washington or Alaska and do not see Premera Blue Cross in the payer drop-down menu for that region and application, contact Availity Client Services at 800-282-4548, 8 a.m. to 8 p.m. ET, Monday through Friday.

    Beginning January 1, 2027, providers will use Availity for eligibility and benefits inquiry, claim submission for professional, facility, and dental claims, claim status, the C3 Claims Editor, remittance viewer including explanation of payments, prior authorization, fee schedules, PCP roster, and electronic funds transfer enrollment and cancellation requests.

    General information about Availity can be found on the Availity FAQ web page.

    Yes, Individual plan member ID numbers are changing. Providers must use 2026 ID numbers for 2026 dates of service and 2027 ID numbers for 2027 dates of service. Starting January 1, 2027, providers should ask individual plan members to show their new ID cards.

    You should enter 2027 ID card numbers into Availity for 2027 dates of service. Claims cannot be adjusted to reflect the current ID number, so the claim would need to be resubmitted.

    Yes. Beginning January 1, 2027, providers will continue using the same claim form, but they will submit claims through Availity or mail them to the new claims address. Professional, facility, and dental claims can be submitted in Availity beginning January 1, 2027.

    The claims mailing address will change to the same address used for Premera commercial plans: PO Box 91059, Seattle, WA 98111-9159.

    Yes. Beginning January 1, 2027, providers can check claim status, detailed payment information, and explanation of payments in Availity.

    Yes. Beginning January 1, 2027, federal Surprise Billing notifications will be included with provider explanation of payments under Premera’s standard process. Today, providers receive a separate letter explaining their rights when a surprise bill claim appears on an explanation of payment.

    Only the notification method will change; how the legislation is applied will stay the same.

    Providers currently use Premera payment and medical policies and will continue to use them in 2027.

    Additionally, policies addressing routine test management will now apply to individual lines of business starting January 1, 2027.

    Standard fee schedules will be available in Availity, which is new for individual plans.

    Beginning January 1, 2027, providers will use the same appeal form used for non-individual plans. Note this form has a different fax number and mailing address than the previous individual plan form.

    Beginning January 1, 2027, new prior authorizations will no longer go through Evolent (Identifi). Providers will submit prior authorizations through Availity or use the standard Premera forms available on Premera.com.

    No, there will no longer be a separate prior authorization code list for individual plans. Providers will use the Premera code list.

    Additionally, individual plans will not have separate or different medical policies for services on the code list. All services will be reviewed using the same medical policy regardless of plan type.

    Open prior authorizations will transfer to Premera systems as of January 1, 2027. All approvals remain subject to member eligibility, plan benefits, and provider network status at the time of service.

    Starting January 1, 2027, Premera will review Individual plan admissions and continued stays. Providers should submit planned admission requests to Premera beginning on that date.

    Evolent will manage all inpatient stays and requests for planned admissions through December 31, 2026. Open authorizations for planned admissions and concurrent reviews for members currently admitted on the transition date will transfer to Premera as of January 1, 2027.

    Prior authorization requests made in 2026 should be submitted to Evolent regardless of the date of service. Requests submitted to Premera in late December 2026 for services scheduled on or after January 1, 2027, may be rejected, delayed, or require resubmission due to new-year eligibility and benefit availability.

    Yes. When retrospective authorization is needed for dates of service before January 1, 2027, providers can submit requests to Evolent until January 31, 2027.

    Yes, providers will still use Carelon for genetic testing, imaging including CT scan, echocardiography, MRI, MRA, nuclear cardiology, PET scan, radiation oncology, and sleep study and sleep medicine.

    Availity will indicate when a service requires prior authorization through Carelon.

    Beginning January 1, 2027, providers servicing individual plan members will use EviCore for outpatient rehabilitation.

    If you need to create an EviCore account, visit the EviCore website or Outpatient Rehabilitation web page.

    Availity will indicate when a service requires prior authorization through EviCore.

    Yes, InstaMed for EFT will be discontinued for dates of service effective January 1, 2027.

    If you are already enrolled for EFT with Premera, EFT payments will automatically process. If you are not registered with Premera for EFT, follow the instructions on Premera’s Electronic Funds Transfer Overview web page.

    After January 1, 2027, providers may continue to receive some EFT payments from InstaMed for dates of service before January 1, 2027.

    Yes, the process for sending refund or overpayment checks will change on January 1, 2027. Refund requests will come from Calypso Overpayment Detection with information on how to submit overpaid amounts. Providers can also use the Overpayment Notification Form to submit a check for the amount overpaid or request that the refund be subtracted from future payments.

    Providers should expect some refund or recovery timing delays due to the transition.

    The customer service phone number, 800-607-0546, will stay the same, but the hours will change to 6 a.m. to 5 p.m. Pacific Time, Monday through Friday.

    All contact information providers need will be updated on the Contact Us web page by the January 1 effective date. Most contact information will be changing to what is currently used for non-individual plans.

    In 2027, Evolent will continue to support historical claims, prior authorizations, appeals, and customer service for 2020 through 2026 plan years and dates of service before January 1, 2027. Providers will use the payer space INDV Plan-Premera Blue Cross (WA) or call customer service to check historical information.