FREQUENTLY ASKED QUESTIONS For LocalSelect Point-of-Service (POS) Plans What Is Piedmont Community HealthCare? Piedmont Community HealthCare, Inc., is a wholly owned subsidiary of Piedmont Community Health Plan, Inc. Piedmont Community HealthCare is a local company formed by the local medical community for local employers and their employees. Piedmont Community HealthCare offers network product options using Piedmont Community Health Plans network of participating physicians and hospitals. Our offices are located at 2512 Langhorne Road in Lynchburg. Members may call our customer service representatives at 1-800-400-PCHP (7247) or locally at 434-947-4463. How does a Point of Service product work? Basically, how and where you choose to receive your medical care determines your level of coverage and the cost of your medical care. You obtain the higher level of benefits at a lower cost when you receive medical care provided by or arranged through your primary care physician. This is called “in-plan,” you receive “out-of-plan” benefits for covered services when you go directly to doctors without having your primary care physician arrange for the service. This is a lower level of benefits with a higher cost to you. An exception is that female members receive two office visits each year to any participating OB/GYN physician or gynecologist without having to obtain a referral from the primary care physician. These services are covered at the in-plan level of benefits. Will I receive a new insurance ID card? Each employee and covered dependent enrolled with Piedmont will receive a Piedmont ID card. This ID card will include the employee's name, the covered person's name, the name of the primary care physician that was selected, a brief description of benefits, and Piedmont's telephone number and claims submission address. We encourage covered members to present their ID cards each time they receive services so that participating physicians will know what coverage the member has. Advantages that Piedmont offers include the following: · Network providers file claims for members covered by Piedmont . · Network providers accept the member's co-payment, coinsurance, or deductible in addition to the payment from Piedmont as payment in full and do not bill for amounts above the "usual and customary" and allowable charge. · Coordination by your primary care physician of all medical care. Employees or covered dependents needing services prior to receiving their ID card should let the physician's office, pharmacy, or other provider know that they are covered by Piedmont as of the group’s effective date. We welcome calls from the employee, covered dependent, physician's office, pharmacy, or other participating providers if there are questions regarding eligibility and covered benefits. We can be reached at 434-947-4463. What if I am traveling outside of the Lynchburg area and I need health care services? What do I have to do in order to receive in-plan benefits for the medical care that I receive while I am out of town? We recognize that covered employees and their families are going to be traveling outside of the Lynchburg area for work assignments, for family vacations or to visit family. Covered members who are out of town and who need emergency care or urgent care services should seek care from the nearest medical facility. Although we know that it is not always possible to contact the primary care physician when services are needed while traveling outside of the Lynchburg area, we encourage members who can do so to contact their primary care physician before receiving services. Covered Piedmont members who need emergency care or urgent care services while outside of the Lynchburg area will receive coverage for these services as if they were in the Lynchburg area and had received these services with a referral from their primary care physician. We ask that members who receive services for emergency care or urgent care while outside of the Lynchburg area call Piedmont at the medical management telephone number on their ID card within two business days of receiving services so that we can make arrangements in the claim system to have the claim for services received processed under in-plan benefits and can help arrange any necessary follow-up care that the member may need. Members who fail to notify us likely will have their claims paid at a lower out-of-plan benefit level since we will have no way of knowing that the services received were as a result of an emergency or urgent situation. However, members in this case may contact us and request that the claim be reprocessed under in-plan benefits by supplying information documenting that the services received were for emergency care or urgent care. Routine care, follow-up care, and elective care received while outside of the Lynchburg area will not be covered under in-plan benefits. No advance referral is needed from the primary care physician for emergency care or urgent care received while outside of the Lynchburg area. What is the difference between emergency care, urgent care and routine care? Emergency care means care received as a result of a bodily injury or serious illness, which threatens loss of life, limb, or senses and requires the member to seek immediate medical attention. Emergencies include heart attacks, hemorrhaging, poisonings, loss of consciousness, and convulsions. Urgent care means care received for a health problem usually marked by the rapid onset of persistent or unusual discomfort associated with an illness or injury. These problems may include high fever, vomiting, sprains, and minor cuts. When in the Lynchburg area, urgent care situations can be handled by contacting the primary care physician, regardless of the time of day or day of the week. When outside of the Lynchburg area, members with urgent care situations may contact their primary care physician or seek care from the nearest available provider and contact Piedmont afterwards. Routine care includes elective services and any other services that are for conditions that are not for emergency care or urgent care. Examples include office visits for consultations or for basic health services (such as treatment for chronic high blood pressure or routine gynecological care), any follow-up care necessary after receiving services for a medical emergency or urgent care situation, and ongoing conditions such as allergy shots or treatment of arthritis. Will I need a primary care physician's referral for my annual check-up and Pap test with an OB/GYN physician? Female members may receive up to two office visits each year to any participating OB/GYN physician or gynecologist under the in-plan benefits without first receiving a referral from the member's primary care physician. If more than two visits are needed to the OB/GYN physician's office or if services are needed outside of the OB/GYN physician's office or if a referral is needed to another specialist physician, then a referral will be needed from the primary care physician for such services. How are referrals to a physical therapist or chiropractor handled? All visits to a physical therapist or chiropractor must receive a referral from the primary care physician. We will work directly with the primary care physician, the physical therapist or chiropractor, and the member when the member needs these services. The referral process for each member is considered individually. Do I need a referral for hospital inpatient services? In order to receive in-plan benefits for covered inpatient services, the member must first receive authorization from the primary care physician and Piedmont. Inpatient services received without authorization or from nonparticipating hospitals are considered out-of-plan. What if I am seeing a specialist now, will I need to get a referral from my primary care physician to this specialist in order to continue treatment? Piedmont's point-of-service product is intended to create a "family doctor" relationship between the member and his/her physician. In order to obtain in-plan benefits, every member must receive a referral from his/her primary care physician prior to receiving services from a specialist physician. In some cases, it may be possible to obtain this referral by telephone from the primary care physician. Extended referrals are available in situations where an ongoing specialist service is being provided. Members who need such a referral should discuss this need with the primary care physician who will make the referral as necessary. We will consider individual circumstances when a covered employee or covered dependent are receiving ongoing follow-up treatment from a nonparticipating physician. Employees to whom this situation applies are encouraged to contact Piedmont in advance of the group’s effective date so that Piedmont and the member's physician(s) can discuss the member's needs in advance. Can your primary care physician be a specialist? If your only doctor is your OB/GYN doctor, do you need to select a primary care physician? Each member enrolled under the Point-of-Service product has to select a participating primary care physician. Primary care physicians are in the specialties of family practice, general, internal medicine, and pediatrics. As stated above, services to be received by physicians other than the OB/GYN physician require a referral from the primary care physician in order to be covered in-plan. If I choose a primary care physician, and that physician is in a group, do I always have to see that one doctor, or can I see anyone in the group? Can a member have more than one primary care physician? While each member needs to name one primary care physician, if that physician is not available when services are needed, the member can see any of the other physicians in the group and receive in-plan benefits. Like the member's own primary care physician, this physician can also refer the member to a specialist physician for services as well. While a member may change primary care physicians during the year, each member can only have one primary care physician at a time. If a member uses an out-of-plan physician and he/she orders blood work (which is done by a participating provider such as Centra Lab), would that blood work be covered under in-plan benefits or out-of-plan benefits? If a member decides to receive services out-of-plan, these services and any tests or follow-up services that may be provided are all considered out-of-plan. What happens if I receive medical care from a network physician without first getting a referral from my primary care physician? In order to receive in-plan benefits for a service, the member has to receive a referral from his/her primary care physician. As noted above, the only exception to this requirement is that female members may receive two office visits annually from participating OB/GYN physicians without a referral from the primary care physician. Any services received from a network provider in which the primary care physician did not first provide a referral will be covered under the out-of-plan benefit. Will I have to file claim forms? Participating physicians will file claims for members when they receive in-plan services. Members may need to file their own claim forms for out-of-plan services. How do I add a newborn child? Newborn children of the female employee or male employee’s spouse may be enrolled under the employee’s coverage. Coverage will be effective as of the date of birth if the newborn is added within 31 days of birth. If you have children away in college, how do they receive medical care? Members who are outside of the area served by Piedmont, including college students, may receive in-plan benefits for urgent or emergency services that are needed while the member is outside of the network area. While routine services are not typically covered outside of the network area, Piedmont makes an exception for covered student dependents outside of the network area. These services are covered at the in-network level. What if I decide that I want to change my primary care physician? We recognize that a member may want to change his/her primary care physician. Any member who wants to change his/her primary care physician can call the customer service telephone number listed on the ID card and indicate the name of the primary care physician that he/she wants to change to. There is no limit on the number of times a member may change primary care physicians. How will pharmacy benefits be administered? Piedmont has developed a pharmacy network service using the services of a large national company called CVS/Caremark. A broad network of local pharmacies and national chain pharmacies participate in the CVS/Caremark pharmacy network. The network directory lists all participating pharmacies. Members needing to fill prescriptions will only need to present their ID card and pay the appropriate co-payment, deductible or coinsurance amount in order to receive prescription benefits. Members can also receive prescriptions through a mail order program by completing the mail order form, enclosing an original copy of the prescription, and sending it to CVS/Caremark at the address shown on the mail order form. These forms can be picked up at the employer’s office or by calling Piedmont at 1-800-400-PCHP (7247) or locally at 434-947-4463. Up to a 31-day or 100 unit supply is available each visit from the retail pharmacy while up to a 90-day or 300 unit supply can be received by mail order with each order. NOTE: Certain walk-in pharmacies have contracted with CVS/Caremark Piedmont to fill 90-day or 300 unit supply for the cost of mail order. Please contact these pharmacies listed in the network directory to verify the benefit offering and find out the details on filling prescriptions. This is a guide to frequently asked questions. The Piedmont Community HealthCare, Inc., Certificate of Coverage [Form No. POSIP(11/07)] and appropriate Schedule of Benefits (Form No. IPPIEDP025, IPPIEDP20020, IPPIEDP50025, IPPIEDC100025, IPPIEDP100025, IPPIEDC150025, IPPIEDA150025, IPPIEDP150025, IPPIEDP20002535, IPPIEDC250025, IPPIEDP250025, IPPIEDP250030, IPPARTP025, IPPARTP20020, IPPART50025, IPPARTC100025, IPPARTP100025, IPPARTC150025, IPPARTA150025, IPPARTP150025, IPPARTP20002535, IPPARTC250025, IPPARTP250025, IPPARTP250030, IPPARTP02545, IPPATP100030, IPPIEDHSAP150025, IPPIEDHSAP250025, or IPPIEDHSAP350030) will prevail for all benefits, conditions, limitations and exclusions.
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