A. Bills submitted by physicians who are in network will have the customary PPO discounts applied.
All bills submitted by facilities or providers who are out of network are repriced using a multiple of Medicare allowable price. This is often referred to as Medicare “plus” reimbursement. For physicians and physician services, reimbursement is at 125% of Medicare allowable. For facilities, reimbursement is at 150% of Medicare allowable.
A. Physicians in your network have agreed to accept your coverage.
Out-of-network provider’s appointments also usually happen without problem. There may be times when the provider needs more information than the ID card provides so that they can properly book the appointment. Simply have the provider call Client Services at 800-714-3432, press 3, and we'll go over the plan details with them.
On very rare occasions, we have providers who are still unwilling to accept Medicare “plus” reimbursement. They may ask you to pay the entire bill at the time of service. If this does happen to you, please contact us immediately and we will take every step possible to resolve the problem.
If you have already paid your visit upfront, please submit your bill to us for reimbursement.
A. A balance bill is a medical bill from a health care provider who is billing a patient for the difference between the total costs of services being charged and the amount the insurance pays.
A fee agreement is reached 100% of the time when you choose a physician in the PPO network and you will never receive a balance bill. You may be balance billed for services provided by an out-of-network providers or facilities, but you will not be responsible for the bill.
Our pledge to you as a member is that we will resolve every balance bill you may get as a result of a discount we've taken. We will do whatever is required to resolve that balance bill.
Go to any physician or facility you like! Use your Physician Only PPO providers or go to an out-of-network provider without any penalty! Out-of-network providers and facilities are paid on a percentage of Medicare.