Healthcare Topics
On this page you will find information about several healthcare topics, so you make the best healthcare decisions for you and your family.
PEHP Member Guide
This guide will help you understand basic health insurance terms, how to maximize your PEHP benefits, and give you the tools you need to make the best healthcare decisions for you and your family.
9/27/18
Need help with your benefits after PEHP regular hours?
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.
Medical Benefits
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 $59 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 Lookup 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. PEHP has contract agreements with MultiPlan/PHCS and BeechStreet for out-of-state coverage. 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 when you log in to your PEHP account in the “My Benefits” section, just look for the “Self-Pay 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 when you log in to your PEHP account in the “My Benefits” section, just look for the “Self-Pay 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.
Pharmacy Benefits
Trouble filling a prescription (Medicare Supplement) » Are you having trouble filling a prescription? To check if your medication is covered, or if it requires pre-authorization, 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 pre-authorization, 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.
08/07/18
When Your Covered Dependent Reaches Age 26
Important Things to Know
General information
- Coverage for your 26-year old dependent will end on the last day of the month in which they turn 26.
- Your dependent may have a number of coverage options:
- COBRA continuation coverage is available through PEHP. COBRA rights and rates will be mailed when coverage ends.
- Coverage is available through the Health Insurance Marketplace.
- Your dependent may be eligible for coverage from their employer or, if married, their spouse's employer.
Time is of the essence. Your dependent has a short window of time after turning 26 to secure coverage. If they fail to do so, they will have to wait until the next open enrollment period to get coverage.
COBRA Continuation Coverage
- Your dependent is eligible for up to 36 months of coverage.
- COBRA costs 102% of the full premium.
- There is a 60-day deadline to enroll after PEHP coverage ends.
- Coverage is continuous from loss of PEHP coverage (no lapse).
- Benefits are identical to previous coverage.
- Plan changes are available only at annual enrollment.
- COBRA coverage can be terminated at any time per member request.
Health Insurance Marketplace
- Marketplace coverage may be more cost effective than COBRA.
- Government subsidies are available for those below 400% of poverty.
- You can compare plans that are offered for coverage levels and costs.
- There is a 60-day deadline to enroll after PEHP coverage ends.
- Resources available to members who are interested include:
- National Marketplace: 800-318-2596 (24/7), English/Spanish/150+ additional languages
If enrolled in COBRA, your dependent can only change to a Marketplace plan during the Marketplace open enrollment period, or if they have another qualifying event such as marriage or birth of a child.
Employer-Sponsored Health Coverage
- Loss of PEHPcoverage is a qualifying event to add other coverage if available through your dependent's employer or their spouse's employer.
- There is typically a 30/60-day deadline to enroll after PEHP coverage ends.
08/07/18
When You Have a Covered Dependent Between Age 18 and 26
Important things to know
- Your child is eligible to stay on your medical coverage until age 26, even if married or not living at home.
- Duplicate PEHP identification cards are available or can be printed for your child.
- Your subscriber ID number will remain on the card.
- Your dependent can create their own PEHP account.
If your dependent is off to college or living out of state/out of country
- We need the out-of-state or out-of-country address of your child. Please call us at 801-366-7755 or send us a message through the Message Center when you log in to PEHP for Members.
- Use MultiPlan network to find in-network providers and avoid balance billing. Visit www.multiplan.com or call 866-591-7427.
- You can compare plans that are offered for coverage levels and costs.
- There is a 60-day deadline to enroll after PEHP coverage ends.
If your dependent is going to serve a church mission
- Typically it is requested or advised that you continue to cover your child on your plan. Please refer to mission guidelines for details.
- Use in-network MultiPlan providers for out-of-state and out-of-country coverage.
If your dependent is getting married
- You must notify PEHP if coverage is acquired because of marriage.
- Call 801-366-7755 if your dependent isn't sure if they should be added to a spouse's plan.
- If your dependent will be covered by their spouse's plan, see detailed Coordination of Benefits information.
- Birth-related healthcare expenses are covered for your child but not grandchild.
If your dependent is working and covered on his/her own employer plan
- PEHP coverage is still available.
- You must notify PEHP within 60 days if other coverage is acquired because of employment.
- Call 801-366-7755 if your dependent isn't sure if they should sign up for their employer's coverage.
- See detailed Coordination of Benefits information.
08/07/18
Preventive Services for Men & Women Age 45 and Older
Regularly getting preventive services may help avoid health problems as you age. Remember, many preventive services are covered by PEHP at 100% when done in-network. See a list of preventive benefits.
Some screenings that may be recommended for you:
- Yearly complete blood count (CBC) and basic/comprehensive metabolic paniel in association with your yearly preventive exam.
- Screening for hypothyroidism.
- Screening for colorectal cancer using annual fecal occult blood test (FOBT) or fecal immunochemical test (FIT), Cologuard every 3 years, sigmoidoscopy every 5 years, or colon screening every 10 years for men and women age 45 to 75 years.
Colonoscopy Information
Get cash back* by using a Value Provider for your next colon screening. The cost of medical care can vary a lot, but you always get the best price when using a Value Provider.
*This benefit isn't available to Salt Lake County employees. For Salt Lake City employees, the incentive will be paid into an HSA. Incentive is subject to income taxes.
Preauthorization » If you get a colon screening, you must get pre-authorization from PEHP for any level of anesthesia higher than “conscious sedation,” which is medically appropriate in most cases. Without preauthorization, you would be responsible to pay for “general anesthesia/ monitored anesthesia care.” Call 801-366-7555 to get pre-authorization.
Preventive » Your colon screening is only considered “preventive” if it is done to screen for colorectal cancer. If it is performed because of a known elevated risk of colorectal cancer or as a form of treatment to, for example, remove known polyps, the colonoscopy is not considered “preventive” and the normal benefit based on deductible and coinsurance would apply. When performing a colon screening, please note doctors will always remove polyps because it is impossible to know if they are cancerous or not.
08/07/18
What to Know About Non-Covered Providers
What is a Non-Covered Provider?
There are certain providers that PEHP won’t pay anything even if you have out-of-network benefits.
PEHP constantly reviews how providers perform. We run reports on provider practices and review member comments left online or reported by phone. Through this process we identify providers that we feel may put you at risk for overbilling, performing services that are considered risky or are not clinically proven, or generally provide services that are not covered by PEHP. When we determine a provider should be classified as a “no pay provider” we notify all members who visited the provider in the last 12 months, provide a list of alternate providers, and inform any referring physicians.
The Non-Covered Provider list is available under the Provider Look Up page.
If you have any questions about this process, please contact PEHP Health Benefits Department at 801-366-7555 or 800-765-7347.
08/08/18
PEHP Coverage Outside of Utah
Living out of state
PEHP provides coverage for you and/or your children while living out-of-state. You must provide us with your out-of-state address, so we can make sure claims are paid correctly and you can access your full benefits coverage.
Make sure you use in-network providers (see Finding an Out-of-State Provider below) whenever possible to get the benefit of PEHP’s contracted rates and avoid balance billing. This includes emergency services.
Traveling out of state
If you’re traveling outside of Utah for business or vacation, you’re covered for any urgent or emergent care needs in another state. Make sure you use in-network providers (see Finding an Out-of-State Provider below) whenever possible to get the benefit of PEHP’s contracted rates and avoid balance billing. This includes emergency services.
However, PEHP does not cover non-emergent or elective services out-of-state. In rare circumstances, it may be necessary to receive services outside of Utah because they’re not available in Utah. Please note these services must be authorized and coordinated through PEHP’s clinical staff in advance. Call us at 801-366-7400 or 855-366-7400.
Finding an out--of-state provider
Log in into your PEHP account and go to our Provider Lookup, then out-of-state network. If you’re looking for a provider in any state but Alaska or Nevada, select the MultiPlan/PHCS search option. If you’re searching for a provider in Alaska or Nevada, select BeechStreet.
Consider consulting a medical professional online 24/7 through E-Care for your urgent care needs.
By using contracted providers, you ensure you get the best discounts and the lowest cost. Remember, providers are contracted only at the addresses listed in the directory.
Please note any urgent or emergent service that is provided by an out-of-network provider may leave you subject to balance billing for any amount above PEHP’s contracted rate.
Traveling or living abroad
PEHP provides coverage while you are traveling or living abroad. PEHP does not have a network for out-of-country providers. Instead, we reimburse out-of-country medical services up to PEHP’s Utah rates, but only if the type of service would normally be covered.
If you have questions about coverage outside of Utah or how to find an out-of-state provider, please contact us at 801-366-7555 or 800-765-7347.
08/08/18
Medical Services Not Covered by PEHP
While your PEHP plan covers most medical services, PEHP doesn't cover certain procedures that are not medically necessary, experimental, or cosmetic. In addition, some services require preauthorization from PEHP before they will be covered to determine medical necessity. See your Master Policy for a list of limited and excluded services. You can also call us at 801-366-7555 or 800-765-7347.
Common Uncovered Services
- Services that require preauthorization that were not authorized by PEHP, including genetic testing, diagnostic 3D mammograms or molecular diagnostics. See list of procedures that require preauthorization.
- Court-ordered drug screening or confirmatory drug testing.
- All charges for services received because of an Industrial Claim (on-the job) injury or illness.
- Residential treatment center which is not providing in-patient services, services for residential treatment, day treatment and/or intensive outpatient treatment. (Most plans don’t cover this. Check your Master Policy).
- Services or medications used for sexual dysfunction or enhancement, including but not limited to: Cialis, Sildenafil, and Viagra.
- Procedures solely for cosmetic purposes such as breast augmentation, rhinoplasty or obesity surgery, including any complications.
- Charges for scholastic education, vocational training, learning disabilities, or behavior modification.
- Diet or nutritional counseling except in conjunction with diabetes education, anorexia, bulimia, or as allowed under the Affordable Care Act.
- Non-FDA approved medications.
Paying for Uncovered Services
Use your HSA or Flex plan money to pay for charges. Many uncovered services are considered “qualified medical expenses” by the IRS, making it possible to use HSA or Flex funds for those services even if PEHP doesn’t pay. See the official list of “qualified medical expenses.”
08/08/18
Get the Best Care by Asking 5 Questions
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 can vary. 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.
05/22/19
Mental Health Care & Services
Life’s struggles can take an emotional toll on you. If you’re struggling with anxiety, depression, substance abuse, or any other mental health condition, you’re not alone. There is help.
Eligible Services
Your PEHP mental health benefit covers treatment for specific mental health conditions. Please note you must have a diagnosis to use this benefit and all providers must be contracted in your PEHP network. Call a PEHP Health Benefits Advisor to see which benefits apply to you, 801-366-7555 or 800-765-7347.
Examples of Ineligible Services
- Conduct disorders
- Marriage counseling
- Parental counseling
- Hypnosis, biofeedback
- Stress management
- Relaxation therapy
- Learning disabilities
See your Master Policy for a complete list of exclusions.
NOTE: Preauthorization is required for some mental health services, including all inpatient mental health services, day treatment facilities, and intensive outpatient programs.
Online Psychiatric Services
If you prefer to seek counseling from the comfort of your home, you can consult a psychiatrist online via Amwell. Since PEHP doesn’t contract with Amwell, you’ll have to pay for the service upfront, then submit a receipt to PEHP using the Self-Pay Medical Claim Form for reimbursement or to apply your payment to your deductible and out-of-pocket maximum. For a list of eligible services, call 801-366-7555 or 800-765-7347. Please note only psychiatric services with Amwell will be treated as in-network.
Other Mental Health Options
If you’re seeking professional care for an ineligible service, consider these options:
- Ask your employer about any Employee Assistance Programs (EAP) or Life Assistance Counseling available to you. Many such plans pay for a limited number of mental health visits, without requiring a specific diagnosis.
- Find local mental health resources at www.211utah.org.
- You may qualify for intensive crisis counseling services. Call the PEHP Member Services Nurse (801-366-3961) to determine if you or a family member may be eligible.
06/20/19
How Does PEHP Pay Providers
PEHP divides providers into three categories for payment purposes: In-Network providers, Out-of-Network providers, and Non-Covered providers. Understanding the difference between the three categories will help you avoid billing surprises.
1. In-Network Providers Paid at Contracted Rates
PEHP contracts with providers for two reasons. First, to get you the best rates possible. Second, to protect you from a provider demanding more than our contracted rate (balance billing).
Contracted rates can and do vary significantly. Be sure to use the PEHP Cost Comparison Tool to see price differences between facilities and providers of the same type.
2. Out-of-Network Providers Paid at Lower Benefits (20%)
You might see an out-of-network provider by mistake or by choice. If you have Out-of-Network Benefits:
- PEHP generally pays 20% less than it normally would to a contracted provider.
- We credit 100% of the cost of seeing an out-of-network provider to your deductible up to the normal contracted rate.
- When you reach your out-of-pocket maximum, we still pay 20% less (80% rather than 100%).
- You don’t have to worry about balance billing for emergency services from an out-of-network hospital in Utah because of contracts we have in place.
If there’s a provider you like but not contracted with PEHP, you can nominate a doctor to add them to your network. If they agree on rates and meet our credentialing requirements, we’ll contract with the provider.
3. Non-Covered Providers Paid $0
There are certain non-contracted providers that PEHP won’t pay anything even if you have out-of-network benefits. It doesn’t mean that you can’t receive services from them. It just means that PEHP will not pay any part of the bill.
Non-covered providers are mainly chiropractors, acupuncturists, drug screening laboratories, and residential treatment centers. There are also individual providers on the List who may put you at risk for overbilling, perform services that may not be medically necessary, or perform services generally not covered by PEHP. See the Non-Covered Provider List.
07/15/19
PEHP is here to help you navigate the challenges and opportunities of health care to avoid unnecessary large medical bills. Below is a list of common medical insurance terms and definitions.
Deductible
Your deductible is the amount you pay toward your claims before PEHP begins paying for certain benefits. Deductibles can vary from hundreds to thousands of dollars depending on your plan. Track your spending toward your deductible at PEHP for Members.
Co-Pay
Your co-pay is a set dollar amount you pay for a service. Some plans require a specific co-payment, such as $25 or $35, for a doctor’s office visit. See your plan's co-payments in your Benefits Summary at PEHP for Members.
Co-insurance
Some plans require you to pay a percentage of cost, such as 20% or 30%, for certain services. This is your co-insurance. See your plan's co-insurance in your Benefits Summary at PEHP for Members.
Claim
A claim is a detailed invoice that your health care provider (such as your doctor, clinic, or hospital) sends to PEHP to collect payment for services you received. This invoice shows exactly what services you received. You can view your claims when you log in to PEHP for Members (click on the "Claims" icon on the top right).
Exclusion
An exclusion is a specific condition, circumstance, or prescription for >which PEHP will not cover. Log in to PEHP for Members to see a list of exclusions in your Master Policy (click "Benefit Information Library" under the "my Benefits" menu).
Balance billing
Balance billing happens when an out-of-network provider charges more than the in-network rate.
Balance billing can result in significant, unexpected bills, because PEHP has no pricing agreements with out-of-network providers. Unless you have made previous arrangements, they are under no obligation to bill within a certain amount. Nothing you pay for balance billing counts toward your deductible or out-of-pocket maximum.
How can you avoid balance billing? First, make sure make sure every person and every facility involved in your care is in your medical or dental network. Find in network providers at PEHP for Members (click “Find Providers and Costs” in the top menu).
If you can’t avoid seeing an out-of-network provider, consider negotiating a price beforehand. It can help to know the in-network fee, which you can find using the cost tools available at PEHP for Members.
Request to have a provider added to your network by filling out this form.
In-Network Rate
The In-network rate is the discounted price that providers in your network have agreed to charge for services. Based on your benefits, you may be required to pay some portion of the in-network rate. Your Benefits Summary describes your member cost-sharing as a portion of the In-Network Rate.
Balance Billing
Balance billing happens when an out-of-network provider charges more than the in-network rate.
Balance billing can result in significant, unexpected bills, because PEHP has no pricing agreements with out-of-network providers. Unless you have made previous arrangements, they are under no obligation to bill within a certain amount. Nothing you pay for balance billing counts toward your deductible or out-of-pocket maximum.
How can you avoid balance billing? First, make sure every person and every facility involved in your care is in your medical or dental network. Find in network providers at PEHP for Members (click “Find Providers and Costs” in the top menu).
If you can’t avoid seeing an out-of-network provider, consider negotiating a price beforehand. It can help to know the in-network fee, which you can find using the cost tools available at PEHP for Members.
Request to have a provider added to your network by filling out this form.
Costs by Type of Facility
Where you get healthcare matters. Rates are always higher for medical services done at a hospital. Some services can only be done at a hospital but others, such as lab work, radiology, elective surgeries, and urgent care can be done in other settings.
For lab work, let your doctor know you want to use an in-network lab that will forward the results to your doctor.
For radiology and certain elective surgeries, consider seeing in-network providers for substantial savings. For example, you could save $1,442 for an MRI at a large multi-specialty clinic.
Large multi-specialty clinics
- Revere Health
- Granger Clinic
- Tanner Clinic
- Ogden Clinic
If you don’t have a medical emergency but need immediate medical attention, visit the nearest Urgent Care Clinic. Also, consider consulting a doctor online through your E-Care benefit for convenient 24/7 urgent care. Connect Care is PEHP’s in-network E-Care provider.
Top 10 Costly Coverage Traps
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 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.
Accountable Care Provider
Get the personalized care you need by visiting an Accountable Care Provider (ACP). Whether it is reaching your health goals or managing an acute or chronic condition, these doctors have accepted additional responsibility to help guide and work with you and other providers for all your care needs. Find them in the Provider Directory.
Motor Vehicle Accidents and Subrogation
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 is that any vehicle registered in the State of Utah is required to carry Personal Injury Protection (PIP) coverage of at least $3,000. Your 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.
Work Related Injuries
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.
New Parents Guide
Are you expecting a baby? Read our New Parents Guide to learn about PEHP maternity benefits, including prenatal visits, prenatal vitamins, delivery, and much more. Remember to add your newborn to your health plan within 30-60 days of birth. Newborn enrollment requirements vary by employer. Call us to learn more, 801-366-7555.
Married? New baby? Divorced? Reasons for Enrollment Changes
If you recently got married, divorced, had a new baby, lost other insurance coverage or any other Qualifying Event, you can add or drop family members from your PEHP plan. Changes to who you cover on your plan can be made when it coincides with a Qualifying Event – birth or adoption of a child, marriage, divorce, dependent reaches age 26, retirement, or Medicare enrollment. It’s important to notify PEHP immediately when you have a Qualifying Event as there is a limited window to make these updates. Call us at 801-366-7555 or use the secure Message Center when you log in to your PEHP account.
Get a Flu Shot
Stay healthy and protect others. Flu shots are covered at no cost to you when you visit a contracted provider.
Top Places to Get a Flu Shot
1. Flu clinic offered at your worksite. (Check with your employer)
2. Your local pharmacy – can't beat the convenience.
3. Your doctor's office – combine with a scheduled visit.
4. Health department – call for more details.
If you have questions, contact PEHP at 801-366-7555.
Gender Dysphoria Information
If you are interested in gender dysphoria benefits, please contact PEHP directly at 801-366-7555 to inquire about specific coverage available to you.
Telephone and Video Visits with In-Network Doctors
- You can do phone visits with your doctor and it will be covered at regular benefits.
- Video visits are only available with doctors who are set up to do so and cost about the same as a regular office visit. If you’re on a traditional plan, the cost is the applicable office copay, based on provider type. If you're on an HSA plan the cost will be 10% less than the regular office visit cost.
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 will thoroughly research the charges and determine whether it is fraud or simply a billing error.
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.
No, this is considered billing for services not provided and should be reported to PEHP immediately.
Never be afraid to report a doctor for suspicion of fraudulent billing or inappropriate behavior. You’re 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 with others as well.
- 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"
- Overutilization 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
If you suspect healthcare fraud you can file a confidential, anonymous complaint by contacting Global Compliance Services, an independent third party, by calling 888-475-8376. You may also submit a confidential, anonymous report here.
Coverage of behavioral health treatment (ABA Therapy)
A brief overview of PEHP’s Autism Spectrum Disorder coverage:
- Please call PEHP (801-366-7555 or 800-765-7347) for information about which autism spectrum disorders and services are covered.
- Therapeutic care includes services provided by speech therapists, occupational therapists, or physical therapists.
- Eligible Autism Spectrum Disorder services do not accrue separately, and are subject to the medical plan’s visit limits, regular cost sharing limitations – deductibles, co-payments, and coinsurance – and would apply to the out-of-pocket maximum.
- Mental health and speech therapy services require Preauthorization.
- No benefits for services received from out-of-network Providers. List of in-network providers is available through your PEHP account or by calling PEHP (801-366-7555 or 800-765-7347).
- Regular medical benefits will apply (see benefits grid for applicable co-pay and coinsurance).
- Not all employers offers this benefit. Call PEHP to see which benefits apply to you
10/27/22
How do I add or remove a dependent?
Dependents must be added or removed within specified periods for qualifying events. Failure to do so can be costly and may result in having to wait until the next plan year for a dependent to be added or removed. This applies to newborns who must be added to be covered. Please check with your employer for specific deadlines for adding or removing dependents. You have a minimum of 30 days to act, and in some cases up to 60 days.
12/27/22
Which services require preauthorization?
For certain services, PEHP requires preauthorization to make sure covered services are medically appropriate. Providers know when preauthorization is required and will request preauthorization on your behalf. If a provider requests preauthorization, you will receive a letter from PEHP letting you know whether it was approved or denied. To see a list of services that require preauthorization, visit www.pehp.org/preauthorization.
12/27/22
How do I find the status of a claim?
To find out the status of your claim, log in to your online account. 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.
12/27/22
How do I know if I’m being overcharged for a service?
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.
12/27/22
What if I disagree with how a claim was paid?
After you receive care, your provider will send a bill for services to PEHP. The document you receive that explains how PEHP paid a claim is called an Explanation of Benefits (EOB). The EOB tells you how much the provider billed, what the agreed upon rate was, how much PEHP paid, and how much you’re responsible to pay. You may also see other explanatory notes in the comment section of the EOB.
Please note the following:
Not every service that may be rendered during a preventive visit will qualify for payment at no cost to you. What qualifies as “preventive” is determined by federal law and PEHP relies on how your provider billed a visit in determining what should be covered at 100% and what should not.
If you see an out-of-network provider, PEHP will pay less than it normally would, including zero under some employers’ policies. There are a few exceptions to this where PEHP will pay the full in-network rate. They include providers of emergency care, providers you see in an in-network facility, and “hidden providers”- such as labs, anesthesiologists, and radiologists.
PEHP pays zero for any provider that is on the no-pay list, which you can find on the Provider Directory.
12/27/22
How do I file an appeal on a claim?
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.
How do I check the status of an appeal?
You can check the status of an appeal online. Some appeals can be lengthy depending on the information being reviewed and if additional information is needed. Please log into your PEHP account frequently for updated status.