Individual Plan Tools and Resources

Availity Essentials is an online portal used by providers to verify eligibility and benefits, check the status of claims, and more.

Sign in to Availity to access the following tools:

• Checking eligibility and benefits
• Viewing claim status
• Reviewing remittance details
• Accessing the primary care provider (PCP) roster

Individual plans appear under a different payer name than commercial plans in Availity. Select INDV Plan – Premera Blue Cross (WA) from the payer drop-down menu.

Learn about our programs that help members navigate the healthcare system and manage their health.

Get claim status, detailed payment information, and explanation of payments (EOPs) on the secure individual plan website.

CMS 1500 online claims submission: The online claims submission tool for HCFA (CMS) 1500 claims currently isn’t available on the individual secure website. In the meantime, submit paper claims, appeals, and other paper correspondence by mail to:

Premera Blue Cross
PO Box 21702
Eagan, MN 55121

Professional and institutional claims: The claim payer ID is 00430 and for dental claims the ID is 47570.

Customer service: Call customer service at 800-607-0546 between 8 a.m. and 6 p.m., Monday through Friday, Pacific Time. Customer service can also provide web support and information on member eligibility and benefits.

Care management: Call care management at 844-996-0329 or fax 888-302-9325.

Availity Client Services:800-282-4548, Monday to Friday, 8 a.m. to 8 p.m. Eastern Time.

InstaMed delivers all electronic funds transfer (EFT) payments and ERA for individual plans. If you submit and receive EFT/ERA through a clearing house, the clearing house needs to sign up for InstaMed. This process isn't completed by Premera EDI. Providers should be enrolled with InstaMed and Premera EDI to ensure they receive all Premera electronic remittance reports.

It's important to sign in to InstaMed and confirm your billing national provider identifier (NPI2) numbers are accurate, current, and match the correct taxpayer identification number (TIN).

EFT enrollment automatically turns off your paper explanation of payments (EOPs) for all Premera business entities and affiliates. After you enroll, you’ll only have online access to your EOPs.

Already have InstaMed?
Great! You’ll automatically receive EFT payments for individual plan claims.

New to InstaMed?
You have two simple ways to sign up:

• Online: Visit instamed.com/eraeft
• Paper: Fax this completed online form to 877-755-3392

Tips about EFT registration through InstaMed
If you’re trying to sign up for EFT through InstaMed, be aware there are some factors that affect the ability to register.

You won’t be able to sign up if you:

• Have TIN/NPI2 number combinations that are missing or mismatched.
• Have a single NPI linked to multiple TINs. InstaMed can’t support electronic payment.

If either of those scenarios apply to you, registration won’t be possible, and you’ll continue to receive paper checks. To update your billing address, please visit our Update Provider Information page.

Individual plan forms:

• Provider appeal submission form with authorization – Member authorization is embedded in the form for providers submitting on a member's behalf. See section C.
• Prior authorization request – Individual plans only use one prior authorization request form for all services including DME and provider-administered infusion drugs.
• Overpayment notification – General instructions for providers.

Visit our forms page for all other provider documents.

If a member has an individual plan, their ID card will say Individual Plan. View a sample member ID card.

View prefix list for Individual Plans.

The secure member eligibility search doesn’t accept member prefixes. Search by member ID or by the member’s last name and date of birth for accurate results.

Review our individual plan policies on our policy page.

Individual plans have a specific code list and InterQual criteria when reviewing certain services.

A form isn't needed for sending us refund (overpayment) checks to Premera. You can submit requests in writing and include the following related to the overpayment:

• Member first and last name and ID number
• Date of service
• Amount and reason for refund
• Primary explanation of payment (if related to coordination of benefits)
  Mail provider refund checks to:
  Premera Provider Refunds
  P.O. Box 840571
  Los Angeles CA 90084-0571

You can submit a prior authorization for Premera Individual plan members using the Identifi online submission tool or you can fax the prior authorization form. View code list.

Access Identifi to submit a prior authorization request. Important: To prevent delays, check the prior authorization code list before submitting a request to see if review is required or should be submitted through Carelon. Care notes, phone numbers, and fax numbers are required fields on the Identifi prior authorization tool.

Once you log in, it takes 1-5 business days to process your access to Identifi. If you need to submit a prior authorization during the waiting period, which automatically starts once you've clicked on the link to the Individual Plan secure provider portal, you can fax your submission or call our utilization management team. You can also call the customer service number on the back of the member ID card. You'll receive a confirmation email once you have Identifi access.

To contact our utilization management team, call 844-996-0329 or fax 888-302-9325. Use this fax number to submit a prior authorization request.

Search for medical providers, facilities, and other specialists within the Premera Blue Cross Individual Signature network.

Complete and email a provider update form if you have any office changes.

Visit the Update Provider Information page to learn about verifying your provider directory information with BetterDoctor, access our provider update form, and more.

Use the following provider training guides to learn more about our individual plan tools:

• Individual plans training overview
• Individual prior authorization tool