Other Helpful Information

As healthcare gets costlier and more complex, carefully consider where and how you get care to maximize your PEHP benefits. Know Before You Go means taking a few simple steps beforehand to assure you get the right care, at the best value, and avoid the nasty surprise of an unnecessary large bill.

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You have the right to know and ask questions about your care. Ask these five questions to make sure you are informed and comfortable with your treatment options.

1. How will this treatment help me?

   The effectiveness of a treatment varies. In fact, some care may even be unnecessary. According to the Institutes of Medicine, more than 30% (or $750B) of healthcare fits this category, which is more than we spend on K-12 education as a nation. Make sure you know how care will help you.

2. What are the potential downsides?

   Healthcare helps make our lives better, but it is not without risks. Even routine treatment can have risks due to infections, errors, and adverse reactions. Make sure you know about the risks of care.

3. Are there simpler, less costly options?

   Healthcare providers can mistakenly assume they know what you want. This can include surgeries over therapy and medications over lifestyle changes. Make sure you know your options, including those that are less costly and less invasive, so you can decide what is best for you.

4. What would happen if I didn't get treatment?

   Our bodies are amazing in their ability to heal. At times, the best option may be to let the body heal naturally or forego a treatment that potentially may do more harm than good. Make sure you know what would happen if you didn’t get care.

5. How much will this cost?

   No one likes to think about costs when it comes to getting the healthcare you need. But it would be a mistake to believe that expensive care is the best care in every situation or that providers who operate in a business environment are not aware of how the cost of care impacts their bottom line. Don’t be afraid to ask about costs. A drug that costs $10 can be better than one that costs $500 and a lab that costs $10 is no different than one that costs $100.

These common issues could unnecessarily cost you up to thousands of dollars.

1. Unexpected out-of-network charges » Be sure all providers are contracted in your network

   Get the best benefit by visiting doctors, hospitals, and other providers contracted in your network. Use the PEHP Provider Directory to find them. Make sure every person and every facility involved in your care is contracted in your network. For example, just because your doctor is in your network, don’t assume the lab he/she uses is too. If your item isn’t available from a contracted provider, or you can’t wait to make arrangements, we can help. If the doctor or hospital is contracted in your network, PEHP will pay for the item up to the allowed amount for contracted providers. However, you must pay the difference between the allowed amount and the billed amount (balance billing), as well as any deductible or co-insurance for the item. Medical equipment – such as a brace or sling – at the doctor’s office or hospital, will likely be billed by a different provider. Make sure that provider is contracted with your network.

2. Preventive services » When the scope of your visit increases, realize you may get charged

   Routine visits for preventive services are covered at no cost to you when you see a doctor contracted in your network that includes medical providers contracted to provide services up to a certain price. When you see providers in your network, your plan generally pays a better, more-predictable benefit. However, you’ll be billed if you get additional services at this visit. An additional service could be something as minor as a discussion with your doctor about a past or current condition. Ask your doctor how the visit will be billed; PEHP pays based on how it’s billed.

3. Emergency room » If you're admitted to the hospital, expect your benefits to change

   Your emergency room benefit covers treatment you get in the emergency room when you’re released the same day. If you start in the emergency room but are taken to another part of the hospital for observation, surgery, or reasons other than diagnostic testing, it’s considered an admission. The benefit changes to an outpatient or inpatient hospital stay, usually subject to your deductible, which is the amount of money you must pay from your own pocket during the plan year before your benefits kick in. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 out-of-pocket for covered healthcare services subject to the deductible. The deductible may not apply to all services, and a percentage, co-insurance, is your share of the cost of a covered healthcare service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. So, if the plan's allowed amount for an office visit is $100 and you've met your deductible, your co-insurance payment of 20% would be $20. The plan pays the rest of the allowed amount.

   After an emergency hospital admission, you or a responsible party have 72 hours to call and notify PEHP. Otherwise, your benefit may be reduced (find details in your benefits summary). The hospital will usually preauthorize for you, but not always. Preauthorization allows us to make sure you get the best possible care.

4. Preauthorization » Know what services require preauthorization and verify it's been done

   Some services require preauthorization. To get it, your doctor must call PEHP. Most doctors know how and when to do this but be sure to verify. Otherwise, your benefits could be reduced or denied. This list shows what services require preauthorization. Testing such as Factor V Leiden requires preauthorization and must be medically necessary. All testing done by Prometheus Labs also requires preauthorization. Genetic testing is commonly overlooked. If you're in doubt, get the procedure codes from your doctor and call PEHP. The PEHP Master Policy has complete details about preauthorization.

5. Covered Services » Verify with PEHP

   Your doctor may tell you a service is covered by your plan, but it’s up to you to verify. Remember, your doctors and their staff may not know all the details of your health plan. Check the benefits summary or call us (801-366-7555) when your doctor orders any surgery or diagnostic testing. Better to be safe than stuck with a huge bill.

6. Repeat dental services » Understand time limits

   PEHP dental plans won’t pay for certain services to be repeated within set time periods. For instance, fillings are allowed only once on the same tooth every 18 months, and panoramic x-rays are allowed only once every three years. If you’re unhappy with the service the first time, talk to your dentist. Most guarantee their work. Call PEHP (801-366-7555) if you have questions about your dental maximums or limitations.

7. Out-of-State Coverage » Use PEHP's out-of-state network

   If you’re living out-of-state or taking an extended vacation, you must notify PEHP. We’ll make sure your claims go through our out-of-state network so you get the best discounts and pay the lowest costs. This applies to covered family members as well, such as children at college in another state.

8. Pharmacy » Use PEHP's Covered Drug List

   The best way to save money on prescription drugs is to be familiar with the PEHP Covered Drug List. Talk to your doctor about cost-saving alternatives, including generics.

If you paid out-of-pocket for a covered medical or dental service, you could get credit toward your plan limits. Complete and send us the Self-Pay Dental & Medical Claim Form with required documentation. Find the form at www.pehp.org/forms.

To find out the status of your claim, log in to your PEHP account and navigate to Claims History under the My Benefits menu. If you can’t find the claim you’re looking for, it means PEHP has yet to receive it. Technically, providers have up to 12 months to submit a claim. If you see that PEHP has received the claim, but it has yet to be paid, it means the claim is pending. While most claims are paid within 30 days, some may take longer.

In-network providers are required to accept your normal cost sharing for covered services as payment in-full. They should not seek anything more from you than that.

If you’ve received emergency care at an out-of-network facility or care from an out-of-network provider at an in-network facility, you are only required to pay your normal cost sharing for covered services.

Providers may only bill you for services you’ve received. It is not uncommon, however, for you to receive services from a provider you never meet, such as a radiologist or anesthesiologist. If you believe that you’re overcharged for a service, call us at 801-366-7555.

To file an appeal, you must submit a written dispute within a 180-days from the date that your claim was processed with supporting documents, records, along with benefit summaries or master policy language you feel PEHP didn’t apply correctly. Appeal forms and instructions can be found online at pehp.org/forms.

Some appeals can be lengthy depending on the information being reviewed and if additional information is needed. You can check the status of an appeal online. Please log into your PEHP account frequently for updated status.

Once your divorce is final, coverage terminates at midnight on the day prior to your divorce date. The divorced spouse is no longer a dependent and if he/she continues using your benefits, you are responsible for any payments made erroneously. Dependent children for whom the subscriber is required to provide medical insurance as ordered in a divorce decree may continue coverage. Stepchildren who no longer have a parental relationship with a subscriber will no longer be eligible to receive benefits under PEHP.

If you need help with your benefits when PEHP offices are closed, you can find valuable information when you log in to your PEHP account, including benefit summaries, claims, forms, lists of participating providers, access your PEHP ID card, and send us information via the Message Center. Below is some helpful information.

Urgent Care » Did you know you can consult a medical professional from anywhere, anytime? With Intermountain Connect Care, you can consult a clinician for non-emergency medical conditions. If you're on the Traditional Plan, it's only $10 per visit. If you're on an HSA plan, the cost is $69 per visit or $10 after you meet your deductible. Connect Care is available on all PEHP networks. Download the Connect Care app. If your condition can’t be addressed remotely, you can find an urgent care center in the PEHP Provider Directory when you log in to your PEHP account. Just click on the “Find a Facility” tab and pick Urgent Care on the list of Facility Types.

Out of State Coverage (not Medicare Supplement) » PEHP members can access a nationwide network of doctors and hospitals for urgent services while travelling, or for regular medical care while living outside Utah. To find an out-of-state provider, log in into your PEHP account and click on the “Find a Provider and Costs” icon on the top right, then out-of-state network. By using in-network providers, you ensure you get the best discounts, the lowest cost, and avoid balance billing.

Out of Country Coverage (not Medicare Supplement) » PEHP provides coverage for members who experience urgent or emergent medical issues while travelling outside the United States. This is a reimbursement benefit. To qualify for this benefit, you’ll need to submit a copy of the original foreign claim and documentation of the services. PEHP will reimburse eligible medical expenses according to your plan’s benefits. You can find a claim form online at www.pehp.org/forms. Search for “Self-Pay Dental & Medical Claim” form. Please note this benefit is only available for members who experience incidental medical issues while travelling. It does not cover medical tourism, complications from medical tourism, or medical evacuation back to the United States.

Medicare Supplement Outside Utah » If you’re a PEHP Medicare Supplement Member, you don’t have to see PEHP doctors and hospitals in Utah. Your PEHP plan follows Medicare guidelines and uses Medicare approved doctors and hospitals, even outside the State of Utah. Just show your Medicare and PEHP cards when you go for services, so your doctor knows you have a supplemental plan. Your PEHP Medicare Supplement plan will pay a percentage of your deductible and coinsurance, after Medicare has made their payment. If you still need assistance, log in to your PEHP account to send us a secure message.

Medicare Supplement Outside USA » PEHP provides coverage for Medicare Supplement members who experience urgent or emergent medical issues while travelling outside the United States. This is a reimbursement benefit. To qualify for this benefit, you’ll need to submit a copy of the original foreign claim and documentation of the services. PEHP will reimburse eligible medical expenses at a percentage, according to your plan’s benefits, with a lifetime maximum of $50,000 per person for out-of-country coverage. You can find a claim form online at www.pehp.org/forms. Search for “Self-Pay Dental & Medical Claim” form. Please note this benefit is only available for members who experience incidental medical issues while travelling. It does not cover medical tourism, complications from medical tourism, or medical evacuation back to the United States.

Trouble filling a prescription (Medicare Supplement) » Are you having trouble filling a prescription? To check if your medication is covered, or if it requires preauthorization, please call Express Scripts at 1-800-922-1557. You can ask your pharmacist to provide you with a short supply of your covered medication or pay out of pocket and submit your claim for reimbursement at your regular benefit level.

Trouble filling a prescription » If you’re not sure your medication is covered or need to check if it requires preauthorization, please review the PEHP Covered Drug List. If you’re not able to resolve your prescription issues and need to pick up your medication today, ask your pharmacist to provide you with a short supply of your medication. If you pay out of pocket for your covered medication, you can submit your receipt for reimbursement at your regular pharmacy benefits.

Submitting a pharmacy claim » If you need to submit a self-pay or secondary pharmacy claim to your PEHP plan, please log into your PEHP account and look for the Express Scripts Personal Account link in the “My Benefits” tab. You will be taken to the Express Scripts website where you can print a form to submit for any eligible reimbursement or to submit claims to your PEHP plan as a secondary carrier.

In the event of a motor vehicle accident, the first $3,000 of medical treatment must be paid for by your personal auto insurance regardless of who was at fault for the accident. Utah is a “no-fault” State for automobile insurance. This means that any vehicle registered in the State of Utah is required to carry Personal Injury Protection (PIP) coverage of at least $3,000. You're responsible to submit a claim to your personal auto insurance, regardless of fault. Once the $3,000 PIP amount has been paid by your auto insurance carrier, they will issue you a “payment ledger.” The payment ledger shows where the $3,000 PIP was distributed. PEHP requires a copy of the payment ledger to coordinate and pay any future medical treatment due to your automobile accident.

If another person is at fault for the accident, PEHP is entitled to reimbursement for any claims PEHP has paid related to the accident. This process is called Subrogation. Your medical Master Policy states that PEHP is entitled to reimbursement out of the settlement proceeds upon finalization of the at fault insurance claim. PEHP will negotiate reimbursement with the liability insurance, however it is your responsibility to ensure that PEHP is repaid in full. You are required to follow through with the at-fault insurance company regarding the bodily injury claim and inform PEHP on all progress.

When an employee is injured while working, they are required to file a claim with the workers compensation insurance carrier and all medical claims should be submitted to the workers compensation insurance for payment. PEHP’s Master Policy excludes coverage for any treatment related to a work injury. Employers are required to have workers compensation insurance.

If the workers compensation insurance carrier determines they are not liable for costs related to the work injury and deny coverage you have two options. First option is to file an appeal with the Labor Commission of Utah if you believe this to be a work-related injury. The second option is to file for a PEHP “internal review.” if you believe the injury was not work related. For the internal review, PEHP may ask for additional information, such as medical records and claim documentation. PEHP will analyze the information and determine if the treatment is the responsibility of the workers compensation insurance. Should the treatment be deemed the liability of the workers compensation insurance, PEHP will not issue any payment on the related claims. If PEHP determines the treatment is not the liability of the workers compensation insurance, then PEHP will process any related claims according to your PEHP benefits.

A primary care doctor can help with short-term problems and take care of you over time, making them a crucial partner for your health. Here are five reasons why having a primary care doctor matters:

1. Consistency: They know your health history and provide personalized care.
2. Prevention: Annual check-ups and vaccinations to keep you healthy.
3. Disease Management: Help you manage long-term illnesses like diabetes and hypertension.
4. Coordination: They interpret results from specialists, labs, and other healthcare providers to guide your next steps.
5. Cost-Effective: Reduce the need for expensive treatments through early intervention. They also help avoid duplicate testing and offer in-office lab work and imaging at a lower cost than the hospital.

Find a primary care physician covered in your network in the Provider Directory under Provider Specialty » Family Practice.