Frequently Asked Questions

My PEHP member identification card was lost or stolen.  What should I do?
If your member card is lost or stolen, you should immediately contact PEHP to prevent payment of services to any unauthorized person.

I received an explanation of benefits for services I didn’t receive.  Is this fraud?
Billing for services not rendered is one of the most common types of fraud committed by providers.  However there are instances when a provider mistakenly submits a claim with an incorrect identification number, causing payment to be issued under the wrong patient.  Always report erroneous charges; PEHP's SIU wil thoroughly research the charges and determine whether it is fraud or simply a billing error.

I'm newly divorced.  Is it Okay to keep my ex-spouse on my coverage?
Once your divorce is final, coverage terminates at midnight on the day prior to your divorce date.  The divorced spouse is no longer a dependant, and if he/she continues using your benefits, you are responsible for any payments made erroneously.  You may also not enroll or continue to cover an ineligible dependent (e.g., married child) on your’ plan coverage. 

My physician billed my health plan for an office visit when all I did was pick up a prescription.  I never saw my physician.  Can he charge for this?
No, this would be considered billing for services not provided and should be reported to PEHP immediately.

I think my physician may be billing fraudulent charges.  If I report this and you later confirm that no fraud was committed, will my provider know I reported him?
You should never be afraid to report a physician for suspicion of fraudulent billing or inappropriate behavior.  You are not required to identify yourself when reporting fraud.  PEHP takes every complaint seriously and is committed to protecting your confidentiality.
Remember, if the provider is filing fraudulent charges regarding you then he/she may be filing wrongful charges under other patients’ coverage as well.

What are the most common types of provider fraud?

• Billing for services not provided
• Double billing
• Billing for services performed by non-licensed or ineligible providers
• "Unbundling" or billing separately for component parts of a medical procedure
• "Up coding" or billing for a higher level of service than was performed
• Billing for services originally advertised as "free"
• Over-utilization of services
• Billing non-covered services as covered services
• Billing under another family member when maximum benefits have been paid on the actual patient
• Prescribing, then offering to buy back powerful narcotics after the insurance has paid for the prescription