Individual Plans

Provider Training

© 2018 Premera. Proprietary and Confidential.050850 (01-11-2021)

© 2018 Premera. Proprietary and Confidential.

Contents 1. Evolent Health

2. Network changes

3. ID cards

4. Primary Care Provider Assignment

5. Medical and payment policies

6. Evolent secure site

7. Online tools and forms

a) Eligibility and benefits

b) Prior authorization

c) Claims

d) Appeals

e) EFT (InstaMed)

8. Evolent directory

9. Training guides and resources

Evolent Health

• Premera partnered with Evolent Health (Evolent) to support administrative

functions for Individual plans.

• This allows us to offer customers access to healthcare and our health plans at a

more affordable price.

Customer Service

Enrollment & Billing

Member Fulfillment

ClaimsComplaints &

Appeals

Payment Reconciliation

Utilization Management

Case Management

Provider Reimbursement

Network Reminders

• The network name for our Premera Blue Cross Blue Shield of Alaska (PBCBS)

individual plans is AK Legacy and Dental Select

• AK Legacy and Dental Select is the same network as AK Heritage–this is a name

change only–and you’ll be reimbursed based on your current PBCBS contract.

• Our PBCBS Individual plans are offered throughout the state.

• BlueCard providers outside of the service area of AK and WA are considered out of

network for non-emergent services and members will have out-of-network cost

shares. Emergency services are always paid at the in-network cost share.

*The only exception is a small handful of non-grandfathered extended Individual

plans that will retain access to the AK Heritage network and BlueCard.

ID cards

Primary Care Providers

• Members can select a primary care provider (PCP) using the Premera “Find a Doctor” tool.

• Members don’t have to select a PCP but they can see their selected PCP for a lower co-pay on most

plans.

• Premera will transfer all current, in-network PCP selections on file for members so they don’t have to re-

select their PCP for the new year plan.

• Members can change PCPs at any point during the plan year effective the first of the following month.

• There isn’t a limit on the number of times a member can change their selected PCP.

Who’s considered a PCP?

Internist Family practice provider

Pediatrician Geriatric practice provider

Gynecologist/Obstetrician Naturopath

Nurse practitioner Physician assistant

Medical and Payment Policies

Provider Training Deck

© 2018 Premera. Proprietary and Confidential.

Medical and Payment Policies

• Evolent uses InterQual® criteria when reviewing certain services.

• You can view the new policies on the Premera medical policy page and on the secure

website.

• Premera payment policies will be used for our Individual plans.

Medical Policies – Premera Website

Go to the Medical

Policies page and

click on ”View

individual plan

medical policies”

Medical Policies – Premera Website

This link will take

you to a page

with important

information about

the Individual

medical plans

and links to the

InterQual criteria

and code list.

Medical Policies – Secure Site

Premera Secure Site + Online Tools

Provider Training Deck

© 2018 Premera. Proprietary and Confidential.

Premera Secure Site

There’s a separate, secure website for Individual health plans managed by Evolent with

the information and tools you need to serve Premera members with an Individual health

plan:

• Eligibility and benefits lookup tool

• Prior authorization code list and submission tool (Identifi)

• Prior authorization submission form (fax option)

• Claims submission tool (HCFA 1500 only)

• Claims list, status lookup, and explanation of payment details

• Medical policies

• PCP roster

• Appeal form (clinical)

• Contact information for customer service and utilization management

Secure Site Access

In OneHealthPort (OHP) click on the

Premera Blue Cross Blue Shield of Alaska

icon.

Secure Site Access

• After you click on the Premera Blue

Cross Blue Shield of Alaska icon, click

on the “Individual Plans” button at the

top of the page.

• This takes you to the new Individual

secure website.

• If you’re looking for Individual plan

information for years prior to 2020, or

the patient's card doesn’t say

"Individual Plan" then log into the “All

Other Plans” site.

All Other Plans**

Secure Site Access

You can also jump to the secure site on the Premera website on the left navigation bar on

the provider homepage.

Eligibility and Benefits

• There’s a new tool available on the secure site to look up eligibility and benefits.

• Providers should NOT enter the member’s alpha prefix when searching for eligibility and benefits.

• Read our detailed guide on how to use the new tool.

Prior Authorization Process

• There’s a new code list code list for Individual plans that you can view on the

Premera website and on the provider secure website.

• You have two ways to submit prior authorizations:

1. Online using Evolent’s prior authorization submission tool, Identifi, available on

the provider secure site.

2. Fax a new prior authorization submission form on the Premera website under

“Forms” and on the provider secure site to 888-584-8081.

o This a different fax number than other Premera group plans.

• Individual market health plans aren’t using eviCore for outpatient prior authorizations.

• Individual plans are using AIM Specialty Health for imaging prior authorizations.

Identifi - Prior Authorization Process

Getting started:

• Providers aren’t required to register with Identifi to start using it.

• Once you sign into your OneHealthPort account, as a new user, and click to access the

Premera Individual Plan secure site. You’ll be granted access to Identifi within 1-5 business

days and will receive a confirmation email once your access is granted. There aren’t any

additional steps you need to take.

• If you need to submit a prior authorization during the 1-5 day waiting period, you can fax your

submission or call our utilization management team directly.

Resources:

• For questions about Identifi, our utilization management staff can answer questions at our

customer service line, 800-809-9361.

• You can also look at our step-by-step guide on how to use Identifi.

Prior Authorization Request Tool (Identifi) + Form

Prior Authorization Request Form (Premera Website)

Claims

• Evolent adjudicates all claims for Individual plans.

• You may notice slight differences in allowed amounts when compared to Premera due to

rounding, edits, or fee schedule update timing, among other factors.

• You have two ways to submit a claim:

✓ Continue to submit claims electronically as you do today.

✓ For paper claims, continue to use the industry standard claims form and mail it to:

Claims mailing address:

Premera Blue Cross Blue Shield of AK

P.O. Box 21762

Eagan, MN 55121

• Claim sequence will start with the calendar year “202X” and there will be a “T” in the center of

the claim number (or a “M” when entered manually).

• BlueCard claims will have “BC” in the beginning of the claim and “B” in the center of the claim

number (instead of “T” or “M”).

Claims – Electronic HCFA 1500 submission

• The online claims submission tool for HCFA (CMS) 1500 claims currently isn’t available on

the individual secure website.

• In the meantime, submit claims by mail to Premera Blue Cross (PO Box 21762, Egan,

MN 55121), through Office Ally, or use your existing software to create and submit

claims electronically.

• Office Ally is a full-service clearinghouse offering a web-based service where providers

can submit claims to Participating Payers (Premera included) at no cost.

• You can check the status of any of your submitted claims and receive a claims list for each

of your patients using available tools on the Evolent secure site.

• Read our step-by-step guide on how to use the Evolent claims tools on the secure site.

Claims – Secure Site

Claims – Premera Website

Appeals

• To submit a clinical appeal on behalf of a patient (denied prior auth):

✓ Submit an appeal form by fax to 844-990-0262. The new form is on the provider secure

site and the Premera Individual Plan Tools web page.

✓ Start an appeal by calling customer service at 800-809-9361.

• To submit an appeal on a claim:

✓ Call customer service at 800-809-9361 and they’ll instruct you on how submit an appeal

letter.

• To request a peer-to-peer review, call customer service at 800-809-9361 and they’ll connect

you with an Evolent medical director.

Appeals Form – Secure Site

Appeals Form – Premera Website

Electronic Fund Transfers (EFT) and Electronic Remittance Advice (ERA)

InstaMed delivers all EFT payments and ERA for our Individual plans.

Already have InstaMed? New to InstaMed?

Great! You’ll automatically receive EFT

payments for our Individual plan claims.

You have 2 simple ways to sign up:

1. Online: www.instamed.com/eraeft

2. Paper: Complete this online form fax it to

877-755-3392.

Electronic Fund Transfers (EFT)

Explanation of Payment

• This an example of an EOP for our

Individual health plans.

• For EFTs, you need to sign up for

InstaMed if you aren’t already

signed up.

• You can also access EOP

statements on the secure site

under “claims.”

• Read our step-by-step guide on

accessing EOPs.

Explanation of Payment – Secure Site

Contact Information + Resources

Provider Training Deck

© 2018 Premera. Proprietary and Confidential.

Contact Information Premera Blue Cross Blue Shield of Alaska Individual Plan

Phone Fax Mailing Address

Customer service 800-809-9361

Utilization (care) management 844-996-0332 888-584-8081

AIM 866-666-0776

EDI/InstaMed 866-467-8263 877-755-3392 Support@Instamed.com

EDI 800-435-2715

Provider relations 877-342-5258, option 4

Pharmacy services 888-261-1756

Claims

800-809-9361

Premera Blue Cross Blue

Shield of AK

PO Box 21762

Eagan, MN 55121

Level 1 appeals Premera Blue Cross Blue

Shield of AK

PO Box 21762

Eagan, MN 55121

Level 2 appeals

844-990-0262

Member Appeals

PO Box 91102

Seattle, WA 98111-9202

Resources

Forms and documents:

• Medical policies:

✓ InterQual criteria

✓ Individual plan medical policies

• Prior Authorizations:

✓ Prior authorization code list

✓ Prior authorization submission form

• Appeals

✓ Appeal form

Training guides for Evolent tools:

• Eligibility and benefits lookup

• Claims (submission and list/status lookup)

• Prior authorization request submission

using Identifi

• PCP Roster lookup

Other Resources:

Regular updates in Provider News

Premera Blue Cross Blue Shield of Alaska is an Independent

Licensee of the Blue Cross Blue Shield Association.