What is a PPO Medical Plan And How Does It Work?
PPO stands for Preferred Provider Organization. In a PPO, members enjoy the freedom to see any physician or other health care professional from the network of participating providers, including specialists, without a referral. With a PPO you will receive the highest level of benefits when you seek care from a contracted network physician, facility or other health care professional. Your out of pocket expense will be significantly less if you access care from "participating" providers. In addition, you do not have to worry about any claim forms or bills.You may also choose to seek care outside the network, without a referral. However, you should know that care received from a non-network physician, facility or other health care professional means a higher deductible and co-payment. In addition, if you choose to seek care outside the network, your insurance company only pays a portion of those charges and it is your responsibility to pay the remainder. We recommend that you ask the non-network physician or health care professional about their billed charge BEFORE your receive care.
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Do I Need to Select a Primary Care Physician?
No - you do not have to select a primary care physician (PCP), there are no referrals, and you choose either in-network or out-of-network providers. Of course when you stay in network, you'll get the highest level of benefits for the lowest cost and you'll avoid having to complete claim forms.
Do I Need a Referral to See a Specialist?
No - you do not need a referral whether you are using in-network providers (commonly referred to as “Participating Providers”) or you are using out-of-network providers (commonly referred to as “Non-Participating Providers”). You will never need a referral.
Although it is certainly NOT REQUIRED, we recommend that you have a relationship with a family doctor to help educate you and help coordinate your care. It helps to feel comfortable with a doctor BEFORE you’re sick or injured. Furthermore:
Are Second Opinions Covered?
You can visit another provider without a referral for a second opinion for your plan's office visit copay. For maximum savings, visit a participating PPO network doctor.
Can I Use an Out of Network Provider?
Yes, you are still covered when you go out of network, but your out of pocket costs will be higher than if you stayed in network. No referrals are needed, however, you may have to pay for services received and file a claim for reimbursement. Some out of network doctors will file the claims with the insurance companies for you - and some will make you pay them in full and file for reimbursement on your own. It all depends on the doctor.
If you choose to use a non-participating provider, you will pay your plan's deductible and coinsurance. Out of network fees are also subject to allowable charges. This means that if your out of network doctor charges higher amounts than the allowable amount, YOU will be responsible for any charges in excess of the allowable charges".
UNDERSTANDING ALLOWABLE CHARGES
The Allowable Charge is the amount on which deductible and coinsurance amounts for eligible services are calculated. Participating providers have agreed to accept fees established with the provider (called network allowance or participating provider allowance) as payment in full. When you seek treatment from non-participating providers, there may be a difference between the allowance and the provider's regular charge or a balance you are responsible to pay. By using participating providers, you can avoid these extra charges.
Where is the List of Participating Providers?
You can access your online provider directly through this employee benefits web site sponsored by your employer. If you do not have access to the Internet, you can call member services using the number on the back of your ID card and have an experienced healthcare professional guide you.
Do I Need Special Pre-Authorization for Hospital Stays?
Yes. Always. All non-emergency hospitalization stays require pre-authorization. Always make sure either you or your doctor calls your insurance company verify benefits and to pre-authorize your hospital stay. If you fail to pre-authorize, there is a financial penalty. Your costs will be lower when you use an in network hospital and your stay has been pre-approved.
In cases of emergency when you don’t have time to pre-certify, make sure to call Member Services at your insurance company within 48 hours and notify them of your hospitalization and applicable medical situation.
How Is Emergency Care Covered?
IN AN EMERGENCY, ALWAYS SEEK MEDICAL CARE IMMEDIATELY. GO DIRECTLY TO THE NEAREST HOSPITAL OR CALL 911. You are not required to obtain prior authorization from your insurance company before receiving emergency care, but if you are admitted into the hospital or receive any type of service that normally would require pre-authorization, you should call your insurance company (or have someone call for you) within 48 hours or as soon as reasonably possible to report the emergency and receive any further assistance or follow-up care.
Examples of emergencies include:
What's the Difference Between Emergency and Urgent Care?
These are sudden and unexpected illnesses or injuries in which loss of life, limb, or severe and permanent medical complications could result if care is not received immediately. Some examples:
If you see any of these symptoms, get medical attention immediately!
These are situations that require prompt medical attention, but are not considered emergencies. Some examples:
If any of these symptoms are present, call your doctor. He or she will direct you to the most appropriate type of care — emergency room, urgent care center, or office visit. Your doctor may also prescribe medications that will make you more comfortable. If your doctor is unavailable, the office will quickly refer you to another doctor.
What if My Family and I Are Traveling and Out of Town?
Your PPO plan is national in scope and may cover you while you are away from home. For emergency care, follow the instructions above. For non-emergency care, simply call member services using the number on the back of your ID card and ask them to give the names, numbers and addresses of the type of doctor, provider, or facility you need within your zip code or city.
You will then be able to see a local doctor within your national PPO network, and go to a local pharmacy and get your prescription filled. The cost will be the same as if you were using these benefits at home.
Remember all PPO networks are NOT nationally recognized. Regional PPO offerings only include networks within your state or region.
Do I File the Claims and Insurance Paperwork or Does My Doctor?
Participating PPO providers will usually file the claims for you. Your PPO plan will determine benefits based on your employer’s specific benefit design, and payment for covered services will be made to the doctor or to you based on the information the insurance company receives. You can call Member Services at the toll-free number on your ID Card to check the status of a claim. Non-Participating doctors do not have to file your claims for you. Some of them will and some of them will not – it depends on the (out of network) doctor.
What if a Provider or Pharmacy Calls and My Insurance Company Tells Them I Am “Not In the System” or That My “Coverage Has Been Terminated”?
Remain calm – this is just an administrative error and it can be corrected within 1-2 business days. Rest assured that if you are signed up for coverage through your employer and are paying for benefits, that you DEFINITELY HAVE coverage. Administrative errors happen in all businesses and it is easy to correct. A copy of your enrollment form, if available, should serve as temporary proof of coverage. Simply check with your Human Resource Department and ask them to make sure you are enrolled correctly into the system. As soon as the administrative error is corrected, you can call the insurance company and have your claims reprocessed with no problem!
What If I Have No ID Card or My ID Card is Lost?
You can call Member Services and request a new ID card to be sent to your home. You should verify that your insurance company has the correct address and you and your family members are properly enrolled in the system.
What If I Need to See a Doctor or Fill a Prescription Before I Receive My Correct ID Card and/or Before Human Resources Has a Chance to Correct My Information with the Insurance Company?
All doctors' offices work differently – so try one of the following approaches:
What If My Claims Are Denied or They Are Paid Incorrectly?
When Can I Change My Benefit Enrollment Information?
You can change your benefit elections once a year during open enrollment.
In addition to open enrollment, a member is allowed to change coverage status for a “life-changing event”. This means getting married, divorced, having a baby, adopting a baby, spouse or dependent losing coverage at their jobs. In all of these cases, you have 30 days to notify your employer and make the change.
You must notify Human Resources in writing to request a change in your benefit elections. Human Resources will need the reason for the change and the effective date of change.
College Student Verification
Dependents are covered to age 19; full time college students are covered to age 23 or 25 depending on your employer’s plan. When a claim is sent to the insurance company for dependents over the age of 19, the claims department will typically “pend the claim” and send you a letter asking for proof of student status. You need to provide them with a copy of your tuition receipt or some form of documentation from the school showing that the student is enrolled with at least 12 credit hours per semester.
Upon receipt of this information, the claim should be processed correctly. If you fail to respond to the request for student verification, they may send out an additional request and keep the claim on hold. If the insurance company does not receive your student verification information in a timely manner, the claim will be denied until verification is received. Keep copies of everything you send in – you may need to provide it more than once.
* (Exact processes may vary from based on the insurance companies internal policy)
Still Have Questions?
For a complete list of contact information, click here. Questions may also be answered by Member Services at the toll-free number found on your ID card, your Human Resources Contact, or Benefits Consultant.
This information is intended to be general and informational in nature, and is not intended to provide you with legal, medical, tax, financial planning or other professional advice.
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