Here you can learn more about Premera’s patient support programs as well as your responsibilities and requirements as a contracted provider.
View summary of benefits and coverage.
Learn about submitting credentialing applications, getting review status, and correcting errors.
Practitioner's Right To Review
Credentialing File Practitioners have the right to review their credentialing files by notifying the Credentialing Department and requesting an appointment to review their file from outside sources (such as malpractice insurance carriers, state licensing boards). Allow up to seven business days to coordinate schedules. We will not make available references, recommendations, or peer-review protected information.
Practitioner's Right To Correct Inaccurate Information
Practitioners have the right to correct inaccurate information. We will notify practitioners in writing if credentialing information obtained from other sources varies from that supplied by the practitioners. Practitioners must explain the discrepancy, may correct any inaccurate information, and may provide any proof available.
Corrections must be submitted in writing within 30 days of notification and can be submitted by mail, fax, or email:
Provider Credentialing Department, MS 263
P.O. Box 327
Seattle, WA 98111-0327
Practitioner's Right To Be Informed of Application Status
Upon request, practitioners have the right to be informed of their credentialing application status. After the initial credentialing process, practitioners who are in the recredentialing cycle are considered approved unless otherwise notified. If you have specific credentialing questions, call the Credentialing Department at 425-918-5080.
We know that patients can get overwhelmed if diagnosed with a serious illness or health condition, or if they have suffered a serious injury. Premera offers a personalized, one-on-one support program to help your patients manage their condition. This service is available at no additional cost.
A registered nurse or clinician including social workers, dietitians, and counselors can help your patients:
Our Personal Health Support clinicians can help providers with any delivery system issues, assist their patients in preparing for appointments, and remove any barriers following the provider's treatment recommendations.
Our Personal Health Support services are available weekdays from 5 a.m. to 8 p.m. and Saturdays 9 a.m. to 5 p.m. Outside these hours, feel free to leave a confidential message and we'll contact you within 24 business hours.
For more information and to request services, please contact us:
Our utilization management program promotes the delivery of appropriate, effective, and efficient care, including medical and pharmacy services and equipment. Here you can learn more about criteria availability, staff access, and our incentive statement.
Access to medical necessity utilization management
Physician and nurse reviewers at Premera use written criteria to assist in the determination of medical necessity. The following medical necessity criteria are used and available to contracted providers upon request:
Providers can request criteria related to a specific medical decision for a patient by calling Clinical Review at 877-342-5258, option 3, 8 a.m. – 5 p.m., Monday through Friday. View our complete medical policies and clinical guidelines.
Access to information about the utilization management process
Providers can contact clinical review staff at 877-342-5258, option 3, during regular business hours, Monday through Friday, 8 a.m. to 5 p.m., Pacific Standard Time, to discuss specific utilization management requirements and procedures or the utilization management process. If calling using a non-toll-free number, the call will be answered by a corporate operator and routed appropriately. Corporate operators are allowed to accept collect calls.
Ensuring appropriate service and coverage
We’re committed to covering our members’ care and encourage appropriate use of healthcare services. Providers and Premera staff who make utilization-related decisions must comply with the following policies:
Medical director calls (also called peer-to-peer)
Providers who receive an adverse decision (denial) related to clinical review for medical necessity or experimental/investigational status can discuss the decision with a physician reviewer. The request may be made by calling 877-835-5672. Often a same-day call back can be arranged.
Please keep in mind the following:
This tool is a clear, easy to understand resource to help your patients make informed healthcare decisions about their medical condition or procedure.
Check out our coding tools and guides to help make coding easier.
Check out our provider learning center for staff training and tool guides.