Medical
PPO Frequently Asked Questions

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.

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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:

  • It gives your doctor the opportunity to get to know about you, your lifestyle, and your personal medical history.
  • You'll be able to learn more about your doctor, the office and staff, and the way the practice works.
  • If you're due for a physical exam, this could be the best time to take care of it.
  • Even if you don't have a checkup, your doctor will set up your medical records file by asking you in detail about your health, family background, job, any medications you are taking, and any recent illnesses or injuries.
  • Your doctor will also ask for the name of your previous doctor and any specialists who've treated you so that he or she can request copies of your records. This information will be an important part of your new file. You will need to sign a release form to have your records transferred.

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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.

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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.

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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.

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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.

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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:

  • Uncontrolled bleeding
  • Seizure or loss of consciousness
  • Severe shortness of breath
  • Chest pain or severe squeezing sensation in the chest
  • Poisoning or suspected overdose of medication
  • Sudden paralysis or slurred speech
  • Severe burns
  • Severe cuts
  • Severe pain
  • Broken bones

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What's the Difference Between Emergency and Urgent Care?

Emergencies

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:

  • Loss of consciousness
  • Uncontrolled bleeding
  • Inability to breathe or severe shortness of breath
  • Poisoning or suspected overdose of medication
  • Severe burns
  • Chest pain or oppressive squeezing sensation in the chest
  • Numbness or paralysis of an arm or leg
  • Suddenly slurred speech
  • Lack of responsiveness
  • Seizures

If you see any of these symptoms, get medical attention immediately!

  • Go to the nearest emergency room
  • Call your area's emergency services number or 911
  • Call your doctor

Urgent Care

These are situations that require prompt medical attention, but are not considered emergencies. Some examples:

  • Ear infections
  • Excessive vomiting
  • High fever
  • Minor burns
  • Sprains
  • Urinary tract infections
  • Prolonged diarrhea

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.

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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.

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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.

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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!

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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.

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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:

  1. Have the doctor try calling member services and identifying you with the social security number of the primary insured (primary insured will be the employee of the company providing your group health benefits). Even if you do not have a card, they can usually verify benefits for the doctor based on the primary insured’s social security number and allow you to receive care.
  2. Explain to the provider that there is an administrative error in your insurance company’s system that will be corrected within 1-2 business days and have the provider file a claim (via the mail) with your PPO Plan. By the time the claim form is received by your PPO Claims Department, your specific information should be updated and the provider will be reimbursed according to the correct benefit level. Remember that all insurance is tracked by the employee’s social security number and the employer’s group account number.
  3. If the doctor will not do #1 or #2, then ask the doctor to send you a bill. By the time you get the bill, your Human Resource Department can probably correct the administrative error and you can ask your doctor to re-file the claim with the insurance company. You can also wait for the bill and submit it to your insurance company and receive the money or have the money sent directly to the provider.
  4. If the doctor will not do #1, #2 or #3, then you may have to pay out of pocket and file a claim form for reimbursement. Again, if you ask your Human Resources Contact to correct your eligibility information, then the insurance company can process your claim quickly and reimburse you for your out of pocket expenses according to your specific benefit plan.
  5. If any of this happens at a pharmacy, you may have to pay for the claim out of pocket and file for reimbursement, or wait 1-2 business days until the administrative error can be cleared up and then go back to the pharmacy and pay the regular pharmacy copay.
  6. In all of these circumstances, make sure the Human Resources Contact notifies the insurance company to update / correct your information in their systems so that the claim gets paid correctly and so that the problem does not happen again.

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What If My Claims Are Denied or They Are Paid Incorrectly?

  1. Make sure that you contact your insurance company first by calling member services using the number on your ID Card. Ask the customer service representative to help you understand why the claim was paid incorrectly.
  2. Make sure to write down the person's name and ask them if your call is being tracked so that if you ever have to call again, there is a record of the conversation and the information they are giving you!
  3. Confirm that you and your family are enrolled properly (by your employer) into the insurance system (remember that the Human Resource Department is ultimately in charge of providing the insurance company with correct eligibility information). If there is a problem with your basic enrollment information, contact Human Resources and ask them to correct it for you.
  4. Once the administrative error is fixed, you can call the insurance company again (when they can see your correct information) and ask them to re-process your claim. This usually works!!!
  5. If there is no resolution after calling customer service, get copies of all related paperwork including claims, bills, collection notices, EOB’s (Explanation of Benefits) and anything else that is relevant. Ask your Human Resource Contact or the Company Benefits Consultant to assist you with the problem. Keep copies of EVERYTHING in case you ever have to contest a credit rating problem as a result of a collection issue. If you are proactive and address these issues right away, then 99% of the time the issue can be resolved before it goes to collection.

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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. 

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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)

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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.

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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.