AdministrativeCommercialJuly 7, 2025

Direct HMO: PPO providers in an HMO network

Direct HMO is an innovative fee‑for‑service (FFS) care model connecting our Pathway HMO members with PCPs and specialists from our PPO network. With some differences, you will be able to treat and bill these HMO members like you would for PPO members.

Are you a Direct HMO care provider?

You can easily verify your participation status using the Find Care tool or by contacting us using the options listed below.

As a Direct HMO care provider, keep these points in mind:

  • As a Direct HMO specialist, please assist Pathway HMO members who are referred to you and avoid redirecting them to other care providers.
  • As a Direct HMO PCP, submit referrals for specialty care, excluding behavioral health and certain other services outlined in the member’s plan.
  • You are reimbursed according to your fee‑for‑service PPO fee schedule.

Refer to the FAQ to learn more about the referral and preapproval process, accessing Direct HMO providers, and support for claims issue resolution.

For more information:

  • Contracts: Email SpecialNetworkReq@anthem.com with Direct HMO in the subject line.
  • Behavioral health utilization management: Call us toll‑free at 800‑274‑7767.
  • Utilization and medical management: Call us toll‑free at 866‑757‑8211.
  • General inquiries: Visit the Contact Us page on our provider website.

Visit the Provider News homepage and search for the key phrase, Direct HMO, to access past newsletters and FAQ.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CABC-CM-085653-25 SRS85648, CABC-CM-085648-25-SRS85648

ATTACHMENTS: Direct HMO FAQ (pdf - 0.22mb)

PUBLICATIONS: August 2025 Provider Newsletter