How do I know whether my plan is a POS or PPO?
The documents provided by your employer describe your plan, including coverage, benefits, conditions, limitations and exclusions. If your plan requires that you select a primary care physician to coordinate your medical care, then you are covered by a Point of Service (POS) Plan. Members who are covered by a preferred Provider Organization plan are not required to select a primary care physician. However, both plans require that members use a physician or other provider who is a member of the Piedmont Community Health Plan network.

How does a PPO (Preferred Provider Organization) plan work?
The PPO plan design utilizes the Piedmont Community Health Plan (PCHP) network of physicians and other providers. This type of plan offers two levels of benefits, in-plan and out-of-plan. When a member uses network providers for covered services, they receive in-plan benefits. This is a higher level of benefits as compared to the out-of-plan benefits. Pre-certification is required for all hospital related services, including inpatient or outpatient care and diagnostic testing. When a member receives covered services from providers that are not in the network or without pre-certification, they receive out-of-plan benefits. This is a lower level of benefits, which costs the member more out-of-pocket than the in-plan level of benefits.

Am I required to select a primary care physician?
No. Members are not required to select or receive services and referrals from a primary care physician in order to receive in-plan benefits.

Is emergency care covered out of the area?
Emergency and urgent care are covered whether the member is in or out of the service area. As long as it is an emergency, care received from non-network facilities will be treated as in-plan. The member should contact Piedmont within two business days to receive the proper authorization for in-plan benefits. Routine care must be received from network providers in order to be covered in-plan.

We ask that members who receive services for emergency care or urgent care while outside of the Lynchburg area call Piedmont Community Health Plan 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.

Is pre-certification required for any type of services?
Yes, pre-certification is required for all elective hospital services. This includes inpatient and outpatient care and diagnostic testing. Pre-certification can be obtained by contacting Piedmont. The proper telephone numbers are on the back of the member's ID card. They are also listed in the Who to Call section.

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 that threatens loss of life, limb or senses and requires the member to seek immediate medical attention. Emergencies include such illnesses as heart attacks, hemorrhaging, poisonings and 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 outside of the Lynchburg area, members with urgent care situations may 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 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 coverage for 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.

Are prescription drugs covered?
Yes, prescription drug coverage is offered with all PPO plan designs. Members must use participating pharmacies in order for the prescriptions to be covered.