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
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
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
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.
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.