Premera Answers FAQs about Premera Blue Cross HMO

The Premera Blue Cross HMO Core Plus Plan uses the Sherwood HMO network of providers in Pierce, Thurston, Spokane, and King counties. To help participating providers support HMO members, here are updated responses to some frequently asked questions:

Referrals

If a patient sees a specialist without a referral from their PCP, who is responsible for payment, the patient or provider?

If there isn’t a referral, the service won’t be covered and the member is responsible for 100% of the cost of the services. Any amount paid won’t apply to their out-of-pocket maximum, except services required by federal or state law.

Can a provider (all areas of specialty) send in a referral after the patient sees a specialist?

Yes, a provider can send a post-service referral within 180 days of the date of service.

Can a specialist refer a patient to another specialist without getting authorization from the member’s assigned PCP?

Yes, an in-network specialist with an approved referral on file may submit a “secondary” referral to another in-network specialist without getting authorization from the member’s PCP. However, we encourage the referring specialist to consult with the member’s PCP to ensure coordination of care.

Is it the responsibility of the referring provider to send the referral or for the specialist to request it?

It is the responsibility of the referring provider (member’s PCP or in-network specialist with an approved referral on file) to submit a request to a specialist.

If the specialist is not in-network and the out-of-network referral isn’t approved by Premera Blue Cross HMO, does the member still have coverage?

No, there are no out-of-network benefits available as part of the Premera Blue Cross HMO plans, except for urgent or emergency situations.

Prior Authorizations

What is the timeframe to complete a prior authorization or referral?

We typically respond to requests within 1-2 days, but it can take up to 5 days. Check the Availity Auth/Referral dashboard for status after submitting the authorization request. Note: Most referrals are auto approved if both the requesting and servicing provider are Sherwood HMO network providers.

How do I submit a prior authorization?

Submit all prior authorizations for Premera Blue Cross HMO through Availity, our secure provider portal. Note: The prior authorization medical policies used for Premera HMO are the same as Premera’s other commercial lines of business. View Availity quick guide for online provider tools.

Is authorization required for outpatient physical therapy?

For School Employees Benefits Board (SEBB) HMO members, no authorization is required for outpatient physical therapy.

For large group HMO members, outpatient physical, occupational, and massage therapy services are subject to medical necessity review for services beyond the initial evaluation and subsequent 6 therapeutic visits, based on episode of care. Authorizations need to be generated by the servicing provider through eviCore Healthcare. You can sign in to eviCore Healthcare, call 800-792-8751, or send an eviCore Healthcare request form by fax to 800-540-2406.

PCP Member Roster

How do I find a list of HMO patients assigned to my provider organization?

The PCP roster tool pulls a list of patients who selected the provider as their PCP or who were assigned to the provider by Premera Blue Cross HMO. The PCP roster tool also contains all the information the provider needs to know about their patient(s).

Providers can access the roster by signing in to Availity, selecting Payer Spaces, then selecting the Premera Blue Cross HMO logo. From there, click on the Resources tab, scroll down, and select the primary care provider (PCP) roster link. Access to the tool requires a OneHealthPort user ID and password. View the provider PCP roster tool guide for step-by-step instructions.

Direct Access and Requirements for Specialists

What is Direct Access?

Certain services don’t require a referral from a PCP. These are called the direct access services. View the list of HMO direct access services.

Pharmacy

Is there any difference in pharmacy services or drug coverage for HMO vs a non-HMO Premera Blue Cross plans?

Most Premera Blue Cross HMO plans (SEBB not included) require the use of exclusive home delivery using the Express Scripts mail-order pharmacy for maintenance medications, designed to be a cost saving strategy for members.

The HMO Core Plus plan is a 4-tier plan using the Essentials formulary. It considers a drug’s clinical efficacy, safety, alternatives, and cost effectiveness in determining a drug tier. The purpose is to help direct members and providers to the highest value medication options (based on quality and cost) when determining a patient care plan.

See our covered drugs web page and select the E4-HMO drug list to learn more and access the full list of generic, brand, and specialty drugs covered under this plan.

ID Card

Will patients have a new ID number and/or a new ID card for the Premera Blue Cross HMO Core Plus plan?

SEBB HMO members currently enrolled on a Premera Blue Cross plan keep their current ID number and receive a new HMO-branded ID card.

Large group HMO members currently enrolled on a Premera Blue Cross plan receive a new ID number and ID card for the HMO plan.

Member Benefits and Eligibility

Where can I find eligibility and benefit information for the Premera Blue Cross HMO Core Plus plan?

Eligibility and benefits for Premera Blue Cross HMO are available through Availity. View Availity quick guide for online provider tools.

For more information on Premera Blue Cross HMO, visit the following resources:

• The HMO provider page has information and resources available.
• The HMO provider training slide deck and 2023 workshop recording.
• Reference manual (includes information on PCP Selection and assignment).
• HMO ID card and ID card guide.
• Provider News for continued updates, and information on the HMO plan.