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 Search 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. Be sure to verify by using the PEHP Provider Search. If your item isn’t available from a contracted provider, or you can’t wait to make arrangements, we can help. As long as 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. If your doctor refers you elsewhere for services? You know what to do. Always verify, and not just by asking your doctor or his/her staff. They may not know, or the network may change without their knowledge.
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. Examples include Advantage Care and Summit Care. 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, available in your benefits library). The hospital will usually pre-notify for you, but not always. Pre-notification allows us to make sure you get the best possible care.
4. Ambulances » Expect to be balance billed if the ER is not contracted in your network
Ambulances are required by law to take you to the nearest facility, regardless of whether it’s contracted in your network. PEHP pays benefits for out-of-network ERs up to the in-network rate that we’d pay an in-network ER. However, at an out-of-network ER, you may be billed the difference between the in-network rate and the billed amount (balance billing), as well as any deductible or co-insurance.
5. 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. Find it in your benefits library.
6. Colonoscopy » Know the type of anesthesia covered
PEHP covers moderate (conscious) sedation when you get a colonoscopy. Check with your doctor and hospital to make sure this is the sedation you’ll get. Propofol is commonly provided with the procedure and not covered separately for routine colonoscopies. General anesthesia or monitored anesthesia care (MAC) requires preauthorization and must be medically necessary. More complex anesthesia must be preauthorized.
7. 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 in your benefits library 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.
8. 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.
9. Out-of-State Coverage » Use PEHP's out-of-state network
If you’re traveling outside of Utah and need urgent care, find PEHP-contracted out-of-state providers. 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.
10. 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.