Direct HMO: Understanding the network design

The Direct HMO fee‑for‑service network design was introduced on January 1, 2025, as part of the Pathway HMO (on and off exchange). This innovative service model groups PPO physicians together to create a network that operates similar to an HMO. We are committed to empowering our care providers with comprehensive education about this groundbreaking opportunity, ensuring sustained success for our members and care provider partners. To learn more about the Direct HMO network, review the information below.

About Direct HMO

Guidelines for care coordination and preapproval:

• Preapproval: Preapproval is required for laboratory tests, radiology, and diagnostic imaging services.
• Referrals: Referrals are required for specialty care so we can help care providers guide patients to appropriate specialists and ensure continuity of care. For complete benefit information, please refer to the member’s Evidence of Coverage.
• Exceptions include behavioral health and other specific services such as reproductive/sexual healthcare and obstetrical/gynecological care.
• Care coordination: Access to our HMO Clinical Operations team toll‑free at 866‑757‑8211 allows care providers to effortlessly coordinate care by streamlining the referral and approval processes, freeing up time to focus on patient care.

Benefits:

• Choosing care providers: Referring patients to contracted care provider partners for laboratory tests, radiology, and diagnostic imaging services ensures streamlined billing processes and minimizes administrative burdens, making it easier for care providers to focus on delivering quality care.
• Extensive specialist network: Referring patients to our extensive network of Direct HMO specialists offers providers access to a collaborative community, improving inter‑provider communication and enhancing patient outcomes. Use our online directory, Find Care, to locate providers in the Direct HMO network. Refer to the FAQ for specific navigational instructions to guide your search.
• Submitting requests: Our Referral and Prior Authorization Request Form ensures timely processing of your referral and authorization requests, reducing wait times and helping care providers maintain efficient practice operations.

A letter was sent to participating providers at the end of September 2024. To verify your participation status, please use the Find Care tool or contact us for more information using the appropriate option below.

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.