PEHP’s Find a Provider gives you a list of contracted providers that are currently on your Network. Using contracted providers is important because they agree to accept our lower, negotiated rate together with your cost sharing responsibility as payment-in-full. Be aware that if you use a non-contracted provider, PEHP will pay less and, in some cases, nothing for your services. In addition, non-contracted providers may seek payment for full billed charges above what PEHP pays unless you have worked out an agreement with them.
Even when you use a contracted provider, you can still run into trouble as explained more fully in your Master Policy.
Here are a few important things to keep in mind:
1. A contracted provider can be terminated from your Network at any time. Be sure to check our Find a Provider tool and make sure that your provider is still in your Network before you obtain any services.
2. PEHP contracts with providers at specific practice locations. This means a provider can be a contracted provider at one location but a non-contracted provider at another location. Be sure to check not only the provider’s name but also the office address where you will be seen to make sure the provider is in your Network for that specific location.
3. If you are receiving services in a facility/hospital/surgical center, always double check to make sure that both the doctor and the facility are part of your Network. A contracted doctor may be on your Network but the facility where you receive a surgical, imaging, or other non-office service may not.
4. Double check when being referred by your Network doctor to other doctors or services. A Network provider may, for example, order a lab test, arrange for imaging services, or include another physician in your treatment. It is possible that the provider of these tests, services, or treatment may not be in your Network. Always check this provider in our Find a Provider tool beforehand to make sure that these secondary providers are in your Network.
5. PEHP requires preauthorization for certain services to make sure that they are medically appropriate for you. If your provider fails to obtain a preauthorization for a service that is not medically appropriate, PEHP will not pay for the service. Talk to your provider before you receive a service about whether preauthorization is necessary and whether it has been received. For a list of services requiring preauthorization, please see use our Cost & Quality Code tool.
PEHP’s payment for medical services is governed by the PEHP Master Policy. The information in this guide is intended as a service to members of PEHP and is not intended to modify or replace the PEHP Master Policy. Please consult your PEHP Master Policy for full details regarding your plan terms and benefits. While Network provider information may be copied and used for your personal benefit, it is not to be used for personal gain.
PEHP provides web links to provider websites for your convenience. PEHP neither controls nor endorses information contained on provider websites.
If you require further assistance in verifying a provider's participation, please contact PEHP Customer Service at 1-801-366-7555 or 1-800-765-7347.