More POS FAQ
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.
