Premera Blue Cross Appeal Guide 2025: WA & AK Provider Timelines

Understanding Premera Blue Cross: Washington & Alaska's Regional Insurer

Premera Blue Cross is the dominant health insurer in Washington (excluding Clark County) and Alaska, operating under the Blue Cross license in Washington and both Blue Cross Blue Shield licenses in Alaska.

Coverage Area:

• Washington State (excluding Clark County) - Since 1933
• Alaska (statewide, all boroughs) - Since 1952
• Over 2 million members combined
• 80%+ of Alaska's healthcare providers in-network

Unlike national insurers, Premera is a regional not-for-profit health plan, which means:

• Medical policies specific to Pacific Northwest healthcare patterns
• Close relationships with WA/AK providers
• Familiarity with regional specialties (aviation medicine in AK, tech occupational health in WA)

Premera Blue Cross Appeal Deadlines: Critical Timelines

Premera has different deadlines for providers vs. members. Missing these deadlines means automatic denial.

Provider Appeal Deadlines

Key Dates to Track

For Providers:

• Day 0: Explanation of Payment (EOP) issued with denial
• Day 365: Last day to file first-level appeal
• Day 395: Premera issues decision (30 days after appeal filed)
• Day 425: Last day to file second-level appeal (30 days after Level 1 denial)

For Members:

• Day 0: Explanation of Benefits (EOB) or denial letter received
• Day 180: Last day to file internal appeal
• Day 210: Premera issues decision (30 days after appeal filed)
• Day 330: Last day to request external review (4 months = ~120 days)

How to File a Premera Blue Cross Appeal: Step-by-Step

Step 1: Choose the Correct Form (Critical for Fast Processing)

Premera has multiple appeal forms depending on who is appealing and what type of plan. Using the wrong form delays your appeal by 7-10 days.

Provider Appeals:

• Commercial Plans: Provider Appeal Form Commercial Plans PBC
• Medicare Advantage: Medicare Provider Appeal Form
• Download from: www.premera.com/wa/provider/reference/forms/

Member Appeals:

• Member Appeal Form (all commercial plans)
• Medicare Appeal Form (Medicare Advantage/Supplement)
• Download from: www.premera.com or request by calling 1-800-722-1471

Step 2: Gather Required Documentation

Premera requires authorization signatures. This is unique to Premera and often causes rejections.

For Provider Appeals, Include:

• ☐ Completed Premera provider appeal form
• ☐ Copy of original EOP showing denial
• ☐ Complete medical records supporting medical necessity
• ☐ Member authorization signature (if provider is appealing on member's behalf)
• ☐ Premera medical policy addressed (cite policy number)
• ☐ Clinical guidelines or peer-reviewed studies
• ☐ Physician statement of medical necessity

For Member Appeals, Include:

• ☐ Completed member appeal form with signature
• ☐ Copy of EOB or denial letter
• ☐ Medical records from provider
• ☐ Provider's letter of medical necessity
• ☐ Any supporting documentation

Step 3: Address Premera's Specific Medical Policy

Premera maintains 300+ medical policies defining medical necessity criteria. You must reference the specific policy that was applied to your denial.

How to Find the Policy:

1. Check your denial EOP - it should list the medical policy number
2. Search Premera's Medical Policy Database: www.premera.com/wa/provider/reference/medical-policies-search/
3. Download the full policy PDF

In Your Appeal:

"Per Premera Medical Policy #[NUMBER] titled '[POLICY NAME]', coverage is
provided when the following criteria are met: [List criteria]. As documented
in the attached medical records, the patient meets all criteria because:
[Address each criterion explicitly]."

Pro Tip: Many Premera policies are adopted from Blue Cross Blue Shield Association (BCBSA). If Premera's policy seems outdated, check if BCBSA has updated guidelines and cite both.

Step 4: Submit Your Appeal (3 Options)

Mail (Most Common):

Premera Blue Cross
ATTN: Member Appeals
PO Box 91102
Seattle, WA 98111-9202

Fax (Faster for Urgent):

• (425) 918-5592
• Send with cover sheet noting number of pages

Email (For Questions Only - Not for Submissions):

• AppealsDepartmentInquiries@Premera.com
• Use for follow-up, not initial filing

Phone (For Expedited/Urgent Only):

• Appeals Department: 855-332-4535 (TTY: 711)
• Request expedited review if clinically urgent

Step 5: Wait for Decision (30 Days Standard)

What happens during review:

Days 1-7:

• Premera acknowledges receipt
• Reviews for completeness
• May request additional information (respond within 10 days)

Days 7-20:

• Clinical reviewer (RN or MD) reviews medical records
• Compares against Premera medical policy
• May contact provider for clarification (peer-to-peer opportunity)

Days 20-30:

• Medical director makes final decision
• Decision letter issued to provider and member
• If approved: Claim reprocesses within 7-10 days

Common Premera Blue Cross Denial Reasons (And How to Fix Them)

Based on analysis of Premera EOP denial edit codes:

1. "Medical Necessity Not Established" (Most Common)

Premera's medical necessity definition (from their policies):

• Service must be appropriate for symptoms/diagnosis
• Provided for diagnosis or direct care
• Within standards of good medical practice in WA/AK medical community
• Not primarily for convenience
• Most appropriate level of service

How to fix:

• Cite specific Premera medical policy criteria
• Document failed conservative treatments
• Reference WA or AK provider standards (e.g., "Per WSMA guidelines...")
• Show severity with objective measurements

2. "Requires Prior Authorization" (Administrative Denial)

Premera requires prior auth for:

• Advanced imaging (MRI, CT, PET)
• Specialty procedures
• High-cost medications ($500+ per month)
• Out-of-network services

How to fix:

• Request retroactive authorization if emergency or urgent
• Document why prior auth wasn't obtained (emergency, administrative error)
• Submit prior auth request with appeal simultaneously
• For Alaska: Cite remote location challenges requiring immediate treatment

3. "Exceeded Benefit Maximum"

Premera limits certain services:

• Physical therapy (often 60 visits per year)
• Chiropractic (30 visits per year)
• Mental health outpatient (varies by plan)

How to fix:

• Request exception to benefit maximum based on medical necessity
• Document ongoing medical need beyond typical patient
• Cite complications or severity requiring extended treatment
• Show risk of deterioration without continued care

4. "Not Covered: Cosmetic/Experimental"

Premera uses strict definitions:

• Cosmetic = primarily for appearance, not function
• Experimental = not FDA approved or widespread clinical acceptance

How to fix:

• Document functional impairment (not just appearance)
• For experimental: Provide FDA approval, peer-reviewed efficacy studies, medical society endorsements
• Show patient-specific factors requiring this treatment
• Cite coverage by other BCBS plans (leverage BCBSA policies)

5. "Coding Error/Invalid Code"

Premera's coding requirements:

• Must use current year CPT/ICD-10 codes
• Diagnosis codes must support procedure codes
• Modifiers required for specific situations

How to fix:

• Verify codes were current on date of service
• Ensure diagnosis justifies procedure (ICD-10 to CPT match)
• Use Premera's Code Check Tool: www.premera.com/wa/provider/code-check/
• Resubmit claim with corrected codes + appeal

Premera-Specific Appeal Strategies for Washington & Alaska Providers

Washington Providers: Leverage Seattle Hub Referral Patterns

Premera understands that Seattle is the regional medical hub (UWMC, Seattle Children's, Harborview).

In your appeals:

• "Patient was referred to UWMC for [specialty service] not available in [city]"
• "Procedure recommended by [Seattle specialist name], one of 3 specialists in Pacific Northwest"
• "Conservative treatment attempted at [local hospital], required tertiary care at [Seattle hospital]"

Premera reviewers expect and approve Seattle referrals for complex cases.

Alaska Providers: Emphasize Geographic Access Challenges

Alaska's geography creates unique medical necessity justifications.

In your appeals:

• "Patient resides in [remote community] with no road access, requiring medevac for specialist care"
• "Telemedicine authorization required due to 300+ mile distance to nearest [specialist]"
• "Weather delays make timely follow-up impossible; expedited treatment medically necessary"
• "Commercial flight required for any specialty care; multiple trips economically prohibitive"

Premera covers Alaska-specific services:

• Telemedicine at higher rates than most insurers
• Air ambulance (medevac) for remote communities
• Out-of-state tertiary care (Seattle, Anchorage to Seattle)

Premera's Alaska reviewers understand these realities. Document them explicitly.

Premera Blue Cross Second-Level Appeals

If your first-level appeal is denied, you get one more internal review before external review.

Second-Level Requirements:

• File within 30 days of first-level denial (shorter than first level!)
• Must be in writing (no phone requests)
• Mail to same address: PO Box 91102, Seattle, WA 98111-9202
• Different medical reviewer than first level

What to add in second-level appeals:

• Address specific reason for first-level denial
• Provide any additional medical records
• Cite any new clinical guidelines published since first appeal
• Request peer-to-peer review with Premera medical director
• Consider adding specialist letter if not included in Level 1

Timeline:

• Premera has 30 days to decide
• If denied, you can request external independent review (free)

External Review: Independent Third Party

If Premera denies both internal appeals, you can request external independent review by medical experts not employed by Premera.

Eligibility:

• Both internal appeal levels exhausted
• Denial involves medical necessity or experimental/investigational treatment
• Member financially responsible for $500+ if denial stands

How to request:

• File within 4 months of final internal denial
• No cost to you (Premera pays for external review)
• Independent medical reviewer makes binding decision

Washington:

• Washington State Office of the Insurance Commissioner oversees
• Contact: 1-800-562-6900 or www.insurance.wa.gov

Alaska:

• Alaska Division of Insurance oversees
• Contact: 1-800-467-8725 or insurance.alaska.gov

Success rate: External reviews overturn approximately 40% of insurance denials nationwide.

Premera Medical Policies: Where to Find Them

Premera maintains evidence-based medical policies defining coverage criteria.

Access policies:

1. Provider Portal: www.premera.com/wa/provider/reference/medical-policies/
2. Search Tool: www.premera.com/wa/provider/reference/medical-policies-search/
3. Phone: Provider Services 1-800-817-8041

Policy sources:

• Premera-developed policies (regional focus)
• BCBSA Technology Evaluation Center (TEC) assessments (nationally adopted)
• Hayes assessments (technology/procedure reviews)
• Pharmacy policies (managed by Express Scripts/eviCore)

Recent policy updates (check quarterly):

• Medical Policy and Coding Updates published every 3 months
• Subscribe to Premera Provider News for automatic notifications

Automate Your Premera Appeals with Muni

Manual Premera Blue Cross appeals take 45 minutes per denial:

• 10 min: Find correct form and Premera medical policy
• 20 min: Write appeal letter addressing policy criteria
• 10 min: Compile documentation and submit
• 5 min: Follow up and track

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What Muni Does for Premera Appeals:

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5. Creates documentation checklist specific to Premera's requirements
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Frequently Asked Questions

How long do I have to appeal a Premera Blue Cross denial?

Providers have 365 days from the EOP date to file a first-level appeal. Members have 180 days from receiving the EOB or denial notice to file an appeal. These deadlines are strictly enforced - late appeals are automatically rejected. Use certified mail to prove timely filing.

What is Premera Blue Cross's timely filing limit for appeals?

For provider appeals, Premera accepts appeals submitted within 365 calendar days from the date on the initial Explanation of Payment (EOP). This is longer than most insurers (typically 180 days). For member appeals, the deadline is 180 days from the denial notice. Second-level appeals must be filed within 30 days of the first-level denial.

How do I contact Premera Blue Cross Appeals Department?

Mail appeals to: Premera Blue Cross, ATTN: Member Appeals, PO Box 91102, Seattle, WA 98111-9202. Fax to: (425) 918-5592. Phone (for urgent inquiries): 855-332-4535 (TTY: 711). Email (questions only, not submissions): AppealsDepartmentInquiries@Premera.com. Provider customer service: 1-800-817-8041.

Does Premera Blue Cross cover Washington and Alaska?

Yes, Premera Blue Cross covers Washington state (excluding Clark County) and all of Alaska. Premera has operated in Washington since 1933 and Alaska since 1952. In Alaska, Premera is the only statewide health insurer with 80%+ of providers in-network. Through BlueCard®, Premera members can access care nationwide.

What forms do I need for a Premera appeal?

Providers need the Provider Appeal Form Commercial Plans (or Medicare form for MA plans). Members need the Member Appeal Form. Download from www.premera.com/wa/provider/reference/forms/ or call 1-800-722-1471 to request. Critical: Provider appeals require member authorization signature if provider is appealing on member's behalf. Using the wrong form delays processing by 7-10 days.

How long does Premera take to decide an appeal?

Premera processes appeals within 30 calendar days for standard reviews. Expedited appeals for urgent medical situations are decided within 72 hours. If Premera doesn't respond within the required timeframe, you can escalate to external independent review through the Washington Office of the Insurance Commissioner or Alaska Division of Insurance.

What is Premera Blue Cross's medical necessity definition?

Premera defines medically necessary services as those that are: (1) appropriate for symptoms, diagnosis, or treatment, (2) provided for diagnosis or direct care, (3) within standards of good medical practice in Washington/Alaska, (4) not primarily for convenience, and (5) the most appropriate level of service that can be safely provided. Your appeal must prove ALL five criteria are met.

Can Alaska providers appeal denials differently than Washington providers?

The appeal process and timelines are the same for Washington and Alaska providers. However, Alaska providers should emphasize geographic access challenges in appeals: remote locations, weather delays, lack of specialists, medevac requirements, and telemedicine necessity. Premera's reviewers understand Alaska's unique healthcare delivery challenges and account for them in medical necessity determinations.

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This guide is updated for 2025 Premera Blue Cross appeal procedures specific to Washington and Alaska. Appeal requirements may vary by plan type (commercial, Medicare Advantage, individual, group). Muni Appeals stays current with Premera policy changes and automates appeals for all Premera plan types.