(The Providence Personal Option Plan - Providence Health Plan is the administrator for PeaceHealth)

All Employees in Oregon

About this Handbook

This handbook is an explanation of your Providence Personal Option Plan (PeaceHealth's In-Network Plan) benefits. For purposes of this summary we will refer to the plan as the In-Network Plan.  Providence Health Plan serves as the administrator for this plan.

It is important to carefully read this handbook. It will help you understand your benefits and responsibilities. If you don’t understand a term that is used, you may find it in "Definitions,".  If you need additional help understanding anything in this handbook, please call your Customer Service Team at 503-574-7500 or 1-800-878-4445. See "Customer Service," for additional information on how to reach your Customer Service Team.

Participating providers for the In-Network Plan are listed in the "Personal Option and Open Option" provider directory at www.providence.org/healthplans. You will need this directory to be able to access covered services. We also list participating providers in a paper directory. To obtain a paper directory, call your Customer Service Team or check with your local human resource department.

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Benefits Summary

This is a summary of benefits only. Please consult your Member Handbook or PeaceHealth's Plan Document for detailed information on Plan use and benefit coverage. Benefits are provided for medically necessary services when provided by a participating physician or provider.

Mental Health / Chemical Dependency

Benefit limitations are for a period of 24 months, beginning new in 2004. All non-emergency treatment must be prior authorized. When combined treatment is received for both chemical dependency and mental health, benefits will be applied toward each category of services as shown below. For example, the maximum benefits in a period of two calendar years for adult outpatient services would be $1875 for chemical dependency PLUS 35 visits for mental health.  The same benefit applies for out-of area members.

To arrange services, call the Plan’s authorizing agent, Mental Health Match at 1-800-457-3798 or 541-744-0828.

	Mental Health		Chemical Dependency
	You Pay	Limits	You Pay	Limits
Inpatient – Adult	$50/day	14 days	$50/day	$5,625
Inpatient – Child	$50/day	15 days	$50/day	$5,000*
Outpatient – Adult	$15/visit	35 visits	$15/visit	$1,875
Outpatient – Child	$15/visit	35 visits	$15/visit	$2,500
Residential/Day – Adult	$50/day	24 days	$50/day	$4,375
Residential/Day – Child	$50/day	24 days	$50/day	$3,750*
*Children’s Floating Reserve Benefit:  An additional $1,875 may be used for either inpatient or residential/day treatment
Out-of-Pocket Limit:  For inpatient and residential care treatment there is a $600 out-of-pocket maximum

Combined chemical dependency maximum benefit: Adults $8,125 / Children $13,125. Detoxification benefits are not subject to the chemical dependency maximum benefit.

General Limitations and Exclusions

Following are the most common limitations and exclusions. Please refer to your Member Handbook or Plan Document for a complete listing. Your employer may have purchased a supplemental benefit offering some of the services listed below. Please call your customer service team if you have questions.

• Some services do not apply to the annual out-of-pocket maximums.

• Cosmetic surgery

• Custodial care and private nursing services

• Dental care, including orthognathic surgery, except as otherwise stated in your Member Handbook or Plan Document

• Experimental/investigational procedures

• Eye surgery which alters the refractive character of the eye, including laser eye and radial keratotomy

• Routine foot care, except for diabetes

• Hearing aids

• Home births and all related services

• In vitro fertilization

• Massage therapy

• Certain mental health services, such as treatment of mental retardation or learning disabilities and self-help programs, including family, marriage, sex and career counseling in the absence of illness

• Non-participating provider services unless prior authorized by the Plan or in an emergency.

• Physical exams primarily for camps, sports, insurance, licensing, employment, or other third-party purposes

• Services and supplies for sexual dysfunction or sexual transformation

• Voluntary termination of pregnancy

• TMJ rehabilitative services are limited to 20 visits per calendar year

• Amounts in excess of usual, customary and reasonable (UCR) charges. These amounts do not apply to out-of-pocket maximums

• Organ transplants, except as otherwise stated in your Member Handbook or Plan Document

• Routine vision exams and eyeglasses

• Weight loss programs and other services and supplies for the treatment of obesity

• Services covered by workers’ compensation or other liability insurance coverage

Other Important Information

If you are an enrolled out-of-area dependent/subscriber, please refer to the Out-of-area Member Summary of Benefits.

How to contact your Customer Service Team

Your Customer Service Team will handle all your needs including claims, enrollment and customer service issues.  Here’s all you need to do to get in touch with your Customer Service Team:

Have your Providence Health Plan member identification card ready when you call. Your card lists your member number.

If you live in:

Portland Metro Area: 503-574-7500

All Other Areas: 1-800-878-4445

TTY (For the Hearing Impaired): 503-574-8702 or 1-888-244-6642

Follow the easy-to-use menu selections to be connected to your Customer Service Team.

Your Customer Service Team is available from 8:00 a.m. to 5:00 p.m., Monday through Friday.

For your information

Your Customer Service Team is available to help you understand your benefits and resolve any problems. Your team will handle:

• Specific benefit or claim questions.
• Address and name changes.
• Questions or concerns about adding or dropping a dependent.
• Enrollment issues.
• Questions or concerns about your health care or service.

Getting and changing information on our Internet site

Our Internet site at www.providence.org/healthplans also can be used as a resource for answering your health plan questions. In addition, you can go to our site and set up your own Providence Health Plan Internet account to gain access to your specific personal health plan information. When you set up your own Internet account, we will give you your own personal identification number (PIN). Your PIN protects your confidentiality. Once you have your PIN, you can go online and have interactive access with your personal health plan information, enabling you to change your address, and do other types of administrative procedures that normally require the assistance of your Customer Service Team.

Member identification card

Each member of a Providence Health Plan receives a member identification card. You must have this card to identify you as a Plan member. Your member identification card lists your member number, your health plan and important phone numbers.

When scheduling an appointment or receiving Plan services, identify yourself as a Providence Health Plan member, present your member identification card and pay your co-payment or coinsurance.

Please keep your health plan member card with you and use it when you:

• Have appointments with your personal physician/provider or other participating provider. If you are a In-Network Plan enrolled Out-of-Area Dependent/Subscriber, please present your card to any non-participating providers you are seeing.
• Call for mental health/chemical dependency customer service.
• Call or write your Customer Service Team.
• Call Providence RN, our medical advice line.
• Receive urgent or emergency health care.

Providence RN — 503-216-6520; 1-800-700-0481

Providence RN is a free medical advice line for In-Network Plan members. You may call Providence RN at 503-216-6520 (Portland metro area) or 1-800-700-0481 (all other areas) (TTY: 503-216-4711) with your health-related questions and speak to a registered nurse, 24 hours a day, seven days a week. Please have your member identification card available when you call.

Members often call when they have sick children at home, or when they have questions about how to treat flus, colds or backaches. After a brief recorded message, a registered nurse will come on the line to help. The nurse can answer many of the questions you may have, or let you know whether you should seek a doctor’s care.

Important note for residents of California: In accordance with California state law, the services of Providence RN are not available to California state residents.

Providence Resource Line — 503-216-6595; 1-800-562-8964
Providence Resource Line is your connection to information and services that may enhance your health and well-being. Our goal is to make it easier for people to stay healthy:

• If you live in the Portland Metro and Newberg areas, you can call Providence Resource Line for help in choosing a physician or provider.
• If you live in the Portland Metro and Newberg areas, you can call Providence Resource Line for information about Providence Health System affiliated providers that are participating with Providence Health Plan. For a complete listing of participating providers in these areas, please see our Online Participating Provider Directory for Personal Option and Open Option Plan members at www.providence.org/healthplans.

Health Education
No matter what your health-related interest, you will find a wide variety of classes to help ensure your success. We can assist you in learning to eat right and manage your weight, prepare for child-birth, learn how to quit smoking and much more. If you have diabetes, health education classes also are available. See "Members Diagnosed with Diabetes," section, for further information. Knowledge is valuable, but it does not have to be expensive. Providence Health Plan members receive discounts on basic health education classes. Your costs, services and the health education available vary by geographic service area. For more information on classes available in your area, call the Providence Resource Line at 503-216-6595 or 1-800-562-8964. Additional wellness information is included in your member packet.

Providence AudioLibrary — 503-216-4720; 1-800-700-0561
Providence AudioLibrary offers recorded information on more than 1,000 health-related topics. You can listen to this information over the telephone, confidentially, and at no charge. For an electronic copy of the AudioLibrary catalog, visit us online at www.providence.org/healthplans. A paper catalog is also available by calling your Customer Service Team and requesting one be sent to you.  

LifeBalance — 503-234-1375 or 1-888-754-LIFE www.LifeBalanceProgram.com
This program, exclusively for members of the Providence Health Plan, provides discounts on a rich variety of recreational and cultural activities throughout Oregon and Southwest Washington. You’ll save on professional instruction, rentals, fitness club memberships, musical events, and much more. Members also have access to discounted member events, such as white-water rafting, ski trips, theater nights, and sporting events.

Learn more by consulting a LifeBalance Directory. To receive a directory, call LifeBalance at 503-234-1375 or 1-888-754-LIFE, or visit the LifeBalance Web site at: www.LifeBalanceProgram.com. Please have your Providence Health Plan member identification card ready when you request LifeBalance discounts.

Wellness information on our Internet site — www.providence.org/healthplans
Visit us online at www.providence.org/healthplans for medical information, class information, information on discount wellness benefits and a wide array of other information listed with your good health in mind.

Participating providers

Providence Health Plan has contractual arrangements with certain physicians/providers. These providers are called "participating providers." Our agreements with these providers enable you to receive quality health care for a reasonable cost. For In-Network benefits to be covered, you must receive health care services from participating providers. Your participating provider will work with the Providence Health Plan to arrange for any prior authorization requirements that may be required for certain covered services.  For more information on prior authorization see In-Plan covered services.

In-Network Plan enrolled Out-of-Area Dependents / Subscribers have a special Out-of-Area benefit allowing them to use non-participating providers. For further information, see the "Enrolled Out-of-Area Dependent /Subscriber Benefits," section.

Native American members may also access Plan covered services from Indian Health Services (IHS) facilities at no greater cost than if the services were accessed through the Plan’s network facilities and providers. For a list of these facilities, please either visit the IHS website at www.ihs.gov, or contact the regional IHS office at: 

Portland Area Indian Health Service
1220 SW Third Ave #476
Portland, OR 97204 

Telephone: 503-326-4123
Fax: 503-326-7280

To encourage optimum health, we promote wellness and preventive care. We also believe wellness and overall health is enhanced by working closely with one physician or provider – your personal physician/provider. He or she can provide most of your care and can track all of your medical care to avoid unneeded or conflicting treatment. To encourage this relationship, your out-of-pocket costs for office visits with a participating personal physician/provider are generally lower. You can, however, see any participating provider you want for covered medical services. When you do this, your out-of-pocket costs will generally be higher. The choice is up to you.

If you are unsure about a provider’s, hospital’s or other facility’s participation in the Providence Health Plan check the "Personal Option and Open Option" Provider Directory at www.providence.org/healthplans before you make an appointment. You also can call your Customer Service Team to get information about a provider’s participation with the Providence Health Plan.

We encourage our members to use our Online Participating Provider Directory for participating provider and hospital information. Our online directory is updated on a frequent basis and includes additional information on each provider, including maps with directions on how to get to your provider’s office from your home. Upon request, however, we will send you a paper directory.

Important Note: In some geographic areas, there may be a limited panel of physicians/providers for a particular medical specialty. In certain cases the Plan may make special arrangements for coverage with additional physicians/ providers in the community. These providers may bill you for charges that exceed the allowable amount that is payable for In-Network benefits. Please see the Online Participating Provider Directory for up-to-date information.

Personal physicians/providers

We recommend that upon joining the Plan you and each of your family members choose a participating personal physician/provider from the Online Personal Option and Open Option Participating Provider Directory as soon as possible. 

In most cases, personal physicians/providers specialize in one or more of the following areas of medicine: family practice, internal medicine, pediatrics, general practice or nurse practitioner practice. Some women’s health care providers also may be approved to serve as personal physicians/providers. These women’s health care providers include physicians specializing in obstetrics or gynecology, nurse practitioners, certified nurse midwives, or physician’s assistants specializing in women’s health care. Women’s health care services received from a naturopath or any other alternative care provider are not covered benefits. 

Important note: Personal physicians/providers agree to serve as a case manager for your care. Not all the providers with the specialties listed above are personal physician/providers. See our Online Participating Provider Directory for a listing of designated personal physicians/providers. 

Your personal physician/provider can provide most of your care and, when necessary, coordinate care with other providers in a convenient and cost-effective manner. Personal physicians/providers provide preventive care and health screening, medical management of many chronic conditions, allergy shots, treatment of some breaks and sprains, and care for many major illnesses and nearly all minor illnesses and conditions. Many personal physicians/providers offer maternity care and minor outpatient surgery as well.

Established patients with personal physicians/providers

If you and your family already see a pediatrician, family practitioner and/or internist regularly, check the provider directory to see if your provider is a participating personal physician/provider for the Providence Health Plan. If your provider is participating with the Plan, let his or her office know you are now an Providence Health Plan member.

Selecting a new personal physician/provider

If you don’t have a regular personal physician/provider or your provider is not a participating provider with the Providence Health Plan, we recommend you choose one from our Online Participating Provider Directory for each covered member of your family. Call the provider’s office to make sure he or she is accepting new patients.

Soon after you select your personal physician/provider, it is a good idea to have your previous physician or provider transfer your medical records to your new personal physician/provider. The first time you make an appointment with your personal physician/provider let him or her know you are now an Providence Health Plan member. On your first visit make a list of questions or information you would like to discuss with your new personal physician/provider, including the following:

• What are the office hours?
• How can I get medical advice after hours?
• What do I do in an emergency?
• Let your personal physician/provider know if you are under a specialist’s care.
• Inform your personal physician/provider of any ongoing prescription medications you are currently taking.

Some women’s health care providers may be approved to serve as personal physicians/providers. These women’s health care providers include physicians specializing in obstetrics or gynecology, nurse practitioners, certified nurse midwives, or physician’s assistants specializing in women’s health care. (Note: Not all these providers are personal physicians/providers – see our Online Participating Provider Directory for a listing of designated personal physicians/providers.)

Changing your personal physician/provider

You are encouraged to establish an ongoing relationship with your personal physician/provider. We understand, however, how important it is for you and your family to feel confident in your choice of providers. If you decide to change your personal physician/provider or your personal physician/provider is no longer participating with the Plan, simply choose a new one from the Online Participating Provider Directory and begin seeing him or her the next time you need medical care. Please remember to have your medical records transferred to your new personal physician/provider.

We recommend you see your personal physician/provider for all routine care and call your personal physician/provider first for urgent or specialty care. If you need medical care when your personal physician/provider is not available, the personal physician/provider on call may treat you and/or recommend that you see another participating provider who specializes in treatment for your condition.

Important note: Sometimes personal physicians/providers may share on call responsibilities with providers who are not personal physicians/providers. If you see a provider who is not a personal physician/provider for any reason, including an on-call situation, you will be responsible for the "other participating provider" member coinsurance, not the personal physician/provider copayment, as stated on your plan’s Summary of Benefits.

Whenever you visit your personal physician’s/provider’s office:

• Bring your Providence Health Plan member identification card with you.
• Make your copayment before you leave your personal physician’s/provider’s office.

Office visits to other participating providers (specialists)

When your personal physician/provider decides you need diagnostic tests or other specialist services, he or she will discuss it with you. Your personal physician/provider may recommend you see a participating specialist for your condition.

You also may decide to see a participating specialist without consulting your personal physician/provider. Check our Online Participating Provider Directory at www.providence.org/healthplans to make sure the provider you choose is a participating provider with the Providence Health Plan. You also can contact your Customer Service Team to verify whether or not a provider is participating with the Plan.

If you decide to see a participating specialist on your own, we recommend you let your personal physician/provider know about your decision. Your personal physician/provider will then be able to coordinate your care and share important medical information with your specialist. In addition, we recommend you let your specialist know the name and contact information of your personal physician/provider.

Whenever you visit a participating specialist:

• Bring your Providence Health Plan member identification card with you.
• Since in most cases your out-of-pocket costs will be a percent of billed services, you will most likely not be able to pay for what you owe at the time of your visit. Your provider’s office will send you a bill for what you owe later. Some providers, however, may ask you to pay for an estimate of what you may owe at the time you receive services and bill or credit you for the balance later.

Prior authorization    

Your participating provider will work with Providence Health Plan to arrange for any Plan prior authorization requirements that may be required for certain covered services. A prior authorization review will determine if the proposed service is medically necessary, eligible as a covered service and if an individual is a member at the time of the proposed service.

For services that do not involve urgent medical conditions- We will notify your provider or you of our decision within 2 business days after we receive the prior authorization request. If we need additional time to process the request for reasons beyond our control, we will complete our review and notify your provider or you of our decision within 7 days after we receive the request. 

For services that involve urgent medical conditions -We will notify your provider or you of our decision within 24 hours after we receive the prior authorization request. If we need additional information to complete our review, we will notify the requesting provider or you within 24 hours after we receive the request and the requesting provider or you will have 48 hours to submit the additional information. We will then complete our review and notify the requesting provider or you of our decision by the earlier of: 

(a)  48 hours after we receive the additional information; or, 
(b)  If no additional information is provided, 48 hours after the additional information was due.  

For specific appeals information regarding prior authorizations, see “Problem Resolution - Appeals involving prior authorization denials,” page 72.

Claims payment

All participating physicians, providers and hospitals submit claims directly to Providence Health Plan. If you receive services from a participating personal physician/provider and have already paid all of your out-of-pocket costs to that provider, he or she may send you an informational statement after billing us. If you receive services from other participating providers, you most likely will receive a bill from your provider’s office for the percentage of coinsurance that you owe unless you paid this when you were in the provider’s office. Pay your provider’s office the amount you owe. Do not pay this amount to Providence Health Plan.

If you see a non-participating provider for a covered service, please send an itemized statement directly to us at:  

Providence Health Plan, Attn: Claims Dept.,
P.O. Box 3125,  

Portland, OR 97208-3125.  

We do not accept claims submitted more than one year after the date of service.

Generally, with the exception of emergency/urgent care services, Personal Option members cannot receive covered services from non-participating providers. Your submission of a claim does not necessarily guarantee payment.

Explanation of Benefits (EOB). You will receive an EOB from Providence Health Plan after we have processed your claim. An EOB is not a bill. An EOB explains how Providence Health Plan processed your claim, and will assist you in paying the appropriate member responsibility to your provider. Co-payment or coinsurance amounts, services or amounts not covered and general information about our processing of your claim are explained on an EOB.

Plan time frames for processing claims. If Providence Health Plan denies your claim we will send an EOB to you with an explanation of the denial within 30 days after we receive your claim. If we need additional time to process your claim for reasons beyond our control, we will send a notice of delay to you explaining those reasons within 30 days after we receive your claim. We will then complete our processing and send an EOB to you within 45 days after we receive your claim. If we need additional information from you to complete our processing of your claim, our notice of delay will describe the information needed and you will have 45 days to submit the additional information. Once we receive the additional information from you we will complete our processing of the claim within 15 days.

Your In-Network Plan has both a per person and per family annual (calendar year) out-of-pocket maximum. These amounts are listed on your In-Network Plan Benefit Summary.  Your maximums are the total amount you or your covered dependents will pay out-of-pocket in any calendar year for covered services. The family maximum combines out-of-pocket costs made by all family members. Once you or your family have paid the maximum amounts listed on your Benefit Summary, you will have no additional out-of-pocket costs for covered services for the remainder of the calendar year.

Out-of-pocket costs that do not apply to deductibles or maximums

For all plans, the following out-of-pocket costs do not apply toward your annual out-of-pocket maximum or any applicable deductibles:

• Services not covered under the Plan.
• Services in excess of any maximum benefit limit.
• Fees in excess of the usual, customary and reasonable (UCR) charges.
• Durable medical equipment and medical supplies and devices.
• Services relating to the diagnosis of infertility.
• Any penalties you must pay if you do not follow the Plan’s prior authorization requirements.
• Payments you make toward meeting any applicable calendar year deductibles.
• Copayments or coinsurance for any supplemental benefits your plan may have such as alternative care or chiropractice care.

Dependents who live outside the the Providence Health Plan service area (including dependents who are away at school) are eligible to become Out-of-Area Dependent members. See the "Definitions," section for the Plan’s definition of "dependent" and "Out-of-Area dependent."

Certain subscribers who live outside the the Providence Health Plan service area who are enrolled on the In-Network plan also are eligible to become Out-of-Area Subscriber members.

This section discusses how enrolled Out-of-Area Dependent In-Network Plan members and enrolled Out-of-Area Subscriber In-Network Plan members can obtain covered services through the Plan’s Out-of-Area benefit.

Out of Area Dependents - To apply for Out-of-Area Dependent benefits, complete an Out-of-Area Dependent Enrollment form, available from your Customer Service Team. If you do not complete an Out-of-Area Dependent Enrollment form, your Out-of-Area Dependent will not be covered for Out-of-Area Dependent benefits.

Out of Area Subscribers - There are special provisions for certain employees who live out of the Providence service area.  For more information, please contact your local Human Resources office.

When you enroll for Out-of-Area coverage, we will send you an Out-of-Area Summary of Benefits. As stated on your Summary of Benefits, a member with Out-of-Area benefits may see any provider, in or out of the service area. The In-Network Plan will pay up to 80 percent of covered charges, with no deductible for eligible benefit services. The Plan’s payment is based on usual, customary and reasonable charges (UCR). Charges which exceed UCR are the member’s responsibility and are not applied to the member’s annual $1,000 out-of-pocket maximum. For a more thorough explanation on UCR charges, see "How the Plan Pays for Non-participating Provider Covered Services (UCR)," section.

Additional Information:

• See "Approved Non-participating Provider Categories," for information regarding Plan-approved non-participating providers.
• See "Submitting Claims for Non-participating Providers," for information on payment of non-participating provider claims.
• See the Out-of-Area Summary of Benefits for specific coverage information.

Prior authorization

Out-of-Area Dependents are responsible for obtaining prior authorization from the Plan prior to receiving certain services from non-participating providers. For further information about prior authorization, including a list of these services and how to obtain prior authorization, see “Non-participating Providers - Including Prior Authorization and Claims Payment."

Change of status

Enrolled Out-of-Area Dependents
These members may change to the subscriber’s In-Area plan benefits when they return to our service area. If they do so, they will receive In-Area benefits. They also must follow Plan procedures for the In-Area plan.

Members who change their status must wait at least 30 days before switching again. For example, if your dependent child returned to our service area for summer vacation, you would need to contact your Customer Service Team to change the child back to In-Area coverage. Then, to be eligible for Out-of-Area coverage again, your child would need to have been covered under the In-Area benefit plan for at least 30 days.

If your dependent comes home for a short visit that is less than 30 days (for example, during Christmas vacation), coverage will remain at the 80 percent Out-of-Area benefit level. Please call your Customer Service Team if you have any questions on a change of status for dependents.

Enrolled Out-of-Area Subscribers

Please contact your PeaceHealth Human Resources office when you return to the The In-Network Plan service area.

This section summarizes basic information enrolled Out-of-Area members, and Open Network Plan/Open Network Plus Plan members using their out-of-network benefit need to know for obtaining covered services from non-participating providers.

This section does not pertain to covered services received from participating providers because your participating provider will work with Providence Health Plan to arrange for any Plan prior authorization requirements.

(Generally, except for emergency or urgent situations outside the Plan’s service area, In-Network Plan members cannot obtain covered services from non-participating providers unless they are enrolled Out-of-Area members.)

Prior authorization

Prior authorization services are services which require you and/or your provider to seek Plan confirmation before seeking or receiving care. A prior authorization review will determine if the proposed service is medically necessary, eligible as a covered service and if an individual is a member at the time of the proposed service. You are responsible for obtaining prior authorization from the Plan prior to receiving certain services from non-participating providers. 

Services that require prior authorization                             
Prior authorization is required for the following services if you receive them from a non-participating provider: 

●    All inpatient admissions, including admission to a hospital, skilled nursing facility or a rehabilitation facility and maternity delivery. For emergency hospitalizations, you, or a relative, need to notify the Plan within 48 hours, or as soon as reasonably possible.

●   All outpatient surgical procedures. 

●   All non-emergency mental health and chemical dependency services must be prior authorized by the Plan’s authorizing agent at
1-800-711-4577. 

●   All human organ/tissue transplant related services. 

●   All hospice services. 

●   Medical supplies, durable medical equipment, appliances and prosthetic devices in excess of $500.  

●   Non-surgical temporomandibular joint syndrome (TMJ) services. (Applicable for enrolled Out-of-Area dependents/subscribers only; all other Plan members are required to use participating providers for these services.) (Clarification) 

●   All outpatient hospitalization and anesthesia for covered dental services. 

●   If you do not obtain prior authorization from Providence Health Plan for the services listed above, you will be responsible for a 50 percent coinsurance penalty. The maximum amount of the penalty will not exceed $2,500 for each covered service occurrence. These penalty amounts do not apply to your out-of-pocket maximums or deductibles. 

For all services except non-emergency mental health and chemical dependency services, simply call 1-800-638-0449 to obtain prior authorization.

For mental health and chemical dependency service prior authorization, call Providence Health Plan’s authorizing agent at 1-800-711-4577.

When you call to request prior authorization, please be prepared to give the following information:

• Member’s name.
• Member’s health plan identification number and group number (these numbers are listed on your Providence Health Plan member identification  card).
• Member’s date of birth.
• Provider’s name, address and telephone number.
• The name of the hospital or treatment facility.
• Scheduled date of admission, or date services are to begin.
• Treatment or procedure to be performed.

For services that do not involve urgent medical conditions - We will notify you or your provider of our decision within 2 business days after we receive the prior authorization request. If we need additional time to process the request for reasons beyond our control, we will complete our review and notify you or your provider of our decision within 7 days after we receive the request.

For services that involve urgent medical conditions -We will notify you or your provider of our decision within 24 hours after we receive the prior authorization request. If we need additional information to complete our review, we will notify you or the requesting provider within 24 hours after we receive the request and you or the requesting provider will have 48 hours to submit the additional information. We will then complete our review and notify you or the requesting provider of our decision by the earlier of, (a) 48 hours after we receive the additional information or, (b) if no additional information is provided, 48 hours after the additional information was due. 
For specific appeals information regarding prior authorizations, see “Problem Resolution - Appeals involving prior authorization denials.” 

When you use non-participating providers, The In-Network Plan provides benefits for covered medically necessary care only when it is received from providers or facilities in approved categories, and when the provider is practicing within the scope of his or her license.

The Plan has approved and may provide reimbursement for non-participating qualified practitioners and facilities. Qualified practitioners are defined as a physician, women’s health care provider, nurse practitioner, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally licensed by the appropriate state agency to diagnose or treat a bodily injury or illness and who provides services covered by the Plan within the scope of that license. A qualified facility is defined as a facility, institution or clinic duly licensed by the appropriate state agency, which is primarily established and operating within the lawful scope of its license.

Important Note: While the Plan will provide reimbursement for covered services received by any of the Plan approved providers listed above, for benefits to be paid you must receive medically necessary covered services as listed in this handbook. All treatment, supplies, and medications excluded by the Plan are not covered no matter what type of approved category of provider you see.

The Plan’s payment to non-participating providers is based on usual, customary and reasonable charges (UCR). Charges which exceed UCR are the member’s responsibility and are not applied to the out-of-pocket maximum.

Example on how UCR charges and your coinsurance for non-participating providers is calculated.

You see a non-participating provider and you are charged $100 for an office visit.	$100
The UCR charge determined for the service is $80.	$80
Your benefit plan has a 20% member coinsurance so the Plan pays 80% of $80, not $100.	(80% of $80 = $64)
Your coinsurance payment for the $80 is $16.	($80 - $64 = $16)
You also may owe the non-participating provider the $20 difference between the amount the provider charged and the calculated UCR charge.	($100 - $80 = $20)
Consequently the total amount you may owe to the non-participating provider would be $36.	($16 + $20 = $36)

UCR calculations are complicated and vary by type of service and where the service is received. There is no precise method for determining the UCR amount until after the provider bills PHP for the services you receive.

Many health care providers will bill your insurance company for you. Please be sure to show your member identification card to your provider. If your provider does not bill Providence Health Plan directly, request an itemized bill suitable for insurance purposes. Send this information with your member identification number on it to: Providence Health Plan, Attn: Claims Department, P.O. Box 3125, Portland OR 97208-3125.

To ensure timely processing of claims, you are encouraged to submit a claim for treatment within 60 days of the date of services. The Plan will not pay claims received more than 12 months after the date of service. However, exceptions will be made if we receive documentation of your legal incapacitation.

Plan time frames for processing claims. If Providence Health Plan denies your claim we will send an EOB to you with an explanation of the denial within 30 days after we receive your claim. If we need additional time to process your claim for reasons beyond our control, we will send a notice of delay to you explaining those reasons within 30 days after we receive your claim. We will then complete our processing and send an EOB to you within 45 days after we receive your claim. If we need additional information from you to complete our processing of your claim, our notice of delay will describe the information needed and you will have 45 days to submit the additional information. Once we receive the additional information from you we will complete our processing of the claim within 15 days. 

Explanation of Benefits (EOB). You will receive an EOB from Providence Health Plan after we have processed your claim. An EOB is not a bill. An EOB explains how Providence Health Plan processed your claim, and will assist you in paying the appropriate member responsibility to your provider. Copayment or coinsurance amounts, services or amounts not covered and general information about our processing of your claim are explained on an EOB. 

A medical emergency is a sudden unexpected illness or injury that you believe would place your life in danger or cause serious damage to your health if you do not seek immediate medical treatment. Medical emergencies include, but are not limited to:

• Heart Attack
• Acute abdominal pain
• Stroke
• Severe chest pain
• Poisoning
• Serious burn
• Loss of consciousness
• Bleeding that does not stop
• Medically necessary detoxification

The definition of an "Emergency medical condition" is a medical condition that manifests itself by symptoms of sufficient severity that a prudent lay person, possessing an average knowledge of health and medicine, would reasonably expect that failure to receive immediate medical attention would place the health of a person (or a fetus in the case of a pregnant woman) in serious jeopardy.

"Emergency Services" are those health care items and services furnished in an emergency department. Services include all ancillary services routinely available to an emergency department to the extent they are required for the stabilization of the patient.

"Emergency Medical Screening Exams" include medical history, examination, ancillary tests and medical determinations required to ascertain the nature and extent of an emergency medical condition.

Your health plan benefits cover emergency services in the emergency room of any hospital in or outside the Providence Health Plan service area. Emergency room services are covered when your medical condition meets the guidelines for emergency care as stated above. Coverage includes services to stabilize an emergency medical condition and emergency medical screening exams.

What to do if you have an emergency

If you or a family member believe that immediate assistance is needed for an emergency medical condition, call 9-1-1 or go to the nearest emergency room. Tell the emergency personnel the name of your personal physician/provider and show them your Providence Health Plan member identification card.

If you’re not sure it's an emergency

Call your personal physician/provider any time, any day of the week. Your personal physician/provider, or the personal physician/provider on call, will tell you what to do and where to go for the most appropriate care. You also may call Providence RN at 503-216-6520 or 1-800-700-0481, if you’re not sure whether to call your personal physician/provider or go to the emergency room. If you believe that taking time to call your personal physician/provider or Providence RN would threaten your life or cause serious damage to your health, call 9-1-1 or go to the nearest emergency room. (In accordance with California state law, residents of California cannot use the services provided by Providence RN.)

Emergency care in the service area and outside the service area

If you are in the Providence Health Plan service area and need emergency services, try to go to the nearest participating hospital. If additional travel time to a participating hospital would endanger your life, or if you are more than 30 miles away from a participating hospital, go directly to the nearest hospital.

If you are outside the Providence Health Plan service area and need emergency services, go to the nearest hospital.

Emergency room co-payment

You are responsible for your plan’s co-payment/coinsurance whenever you receive services in an emergency room, unless you are admitted to a hospital within 24 hours. Please be prepared to pay your co-payment/coinsurance at the time you receive care. You are responsible for your plan’s co-payment/ coinsurance for each hospital emergency room visit. Please refer to your Summary of Benefits for your co-payment/coinsurance amounts and any applicable deductibles.

Services not covered

The Plan does not pay for emergency room treatment for medical conditions that are not medical emergencies. Do not go to the emergency room for care that should take place in your provider’s office. Routine care for sore throats, common colds, follow-up care, and prescription drug requests are not considered to be emergencies.

Eye emergencies

If you have an emergency medical condition involving injury or illness to your eye(s), you may receive services directly from an optometrist or ophthalmologist or a hospital emergency room.

Psychiatric emergency

Emergency services are provided for psychiatric, mental health and chemical dependency conditions that in the reasonable judgement of a prudent layperson would place your life in danger or cause serious damage to your health if immediate care is not received. If you have a psychiatric emergency or crisis and receive emergency treatment at a specialized mental health facility that handles emergency care, the emergency room copayment/coinsurance will apply.

What to do if you are admitted to a non-participating hospital

If you are admitted to a non-participating hospital, you, or a relative, should call the Plan within 48 hours or as soon as reasonably possible. All approved services will be covered at usual, customary and reasonable (UCR) charges. You will be responsible for any copayments and all amounts above the UCR charges.

You will need to submit a claim for a non-participating hospital service if the provider does not submit it for you. For information on how to submit a claim, see "Additional Information".

Urgent care is treatment you need right away for an illness or injury that is not life threatening. This includes, but is not limited to, minor sprains, minor cuts and burns, and ear, nose, and throat infections. Routine care that can be delayed until you can be seen by a physician or provider in his or her office is not urgent care.

Whenever you need urgent care, call your personal physician/provider first. You also may call Providence RN at 503-216-6520 or 1-800-700-0481, if you’re not sure whether to call your personal physician/provider or go to the urgent care center. (In accordance with California state law, residents of California cannot use the services provided by Providence RN.) Your personal physician/provider or personal physician/provider on call is always available, day or night. He or she may either suggest that you come to the office, or go to an emergency room or urgent care facility. If you can be treated in your provider’s office or participating urgent care facility, your copayment/coinsurance usually will be lower. You are responsible for your plan’s copayment/coinsurance whenever you receive services in an urgent care clinic, unless you are admitted to a hospital within 24 hours. Please be prepared to pay the copayment/coinsurance at the time you receive care.

If you are admitted to a non-participating hospital, you, or a relative, should call the Plan within 48 hours or as soon as reasonably possible.

The Plan pays for urgent care wherever you are. If you are injured or seriously ill while you are away from the Plan service area, go to any provider or urgent care facility.

The Plan does not cover non-urgent care such as check-ups or follow-up care while you are outside the Plan service area.

For urgent care services inside the Plan’s service area, please try to go to a participating urgent care facility. If there are no participating urgent care facilities available, however, the Plan will cover urgent care services received from a non-participating urgent care facility.

Additional information

If you receive services from an urgent care facility or emergency room from a non-participating facility outside or inside the Plan’s service area, you must submit a claim if the facility or provider does not submit it for you. Submit claims to: Providence Health Plan, Attn: Claims Department, P.O. Box 3125, Portland OR 97208-3125. We request that you submit your claim within 60 days of receiving the service. To be paid, claims must be submitted within 12-months of receiving the service.

Please call your Customer Service Team at 1-800-878-4445 if you have questions about this benefit or if you would like additional information.

This section lists your covered benefits in the same order that they appear on your Summary of Benefits. Please refer to your Summary of Benefits for your member copayments/coinsurance as well as other details of your specific coverage. If the Plan is required by law to modify your benefits, you will be notified in writing prior to any changes.

Except as otherwise stated in "Using your Benefits,", you must use participating providers to receive benefits for the covered services listed in this section.

(Also please see "Wellness Benefits," for additional benefits.)

Periodic health exams

Your provider will determine which tests are necessary for your physical exam according to your medical history and your current health status. More frequent exams will be covered if your provider determines that they are necessary.

Recommended guidelines:

Well baby care, up to eight provider office visits during a child’s first 24 months.

• For children age 2-6, one exam per year.
• For children age 7-18, one exam every two years.
• For adults age 19-29, one exam every five years.
• For adults age 30-39, one exam every three years.
• For adults age 40-49, one exam every two years.
• For adults age 50 and above, one exam every year.

If, at the time of your routine physical examination or well child care, you need paperwork completed for a third party such as school, camp, team sports, etc., your provider may charge you a fee to complete the paperwork. The Plan will not cover this additional fee.

Preventive care for women and men

Preventive exams for adult females and adult males include screening tests to detect conditions of the female or male reproductive system. These tests include breast and pelvic exams, mammograms, Pap tests and prostate exams. The age for your initial exam and frequency of these exams will be determined between you and your provider according to your history and health status. See "Women’s Health Care Services,", for additional details on preventive care for women.

Immunizations /vaccinations

Routine immunizations/vaccinations (shots) are covered. Coverage for immunizations is provided when ordered or arranged by your provider and received in the provider’s office. Visits to your provider’s office for immunizations are subject to a copayment or member coinsurance. Immunizations required for travel, employment, insurance, licensing purposes or solely for the purpose of participating in camps, sports activities, recreation programs, or college entrance are not covered.

Children’s vision and hearing screenings

Annual vision and hearing screenings by a provider are covered for children through age 17. If a vision or hearing problem is discovered, the Plan will pay for one visit per calendar year to an eye or hearing specialist to determine the need for vision or hearing correction.

Covered services do NOT include:

• Services for laser surgery, radial keratotomy and any other surgery to correct myopia, hyperopia or stigmatic error; vision therapy, or orthoptic treatment (eye exercises).
• Services for routine eye and vision care, refractive disorders, eyeglass frames and lenses, and contact lenses.
• Hearing aids, including all services related to the examination and fitting of the hearing aids.

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Members diagnosed with diabetes

Members diagnosed with either insulin dependent or non–insulin dependent diabetes mellitus, have the following preventive health care benefits:

Regular Exams

• The following exams are provided annually: Dilated retinal exams by a qualified participating eye care specialist; glycosylated hemoglobin (HbAlc) test; urine test to test kidney function; blood test for lipid levels as appropriate; visual exam of mouth and teeth by a personal physician/provider or other provider (dental visits are not covered); foot inspection without shoes or socks; influenza vaccine.
• Pneumococcal vaccines are provided every five years.
• NOTE: With the exception of the dilated retinal exam, all of the above may be performed in your provider’s office at the time of your annual exam. The eye exam may be done by an eye care specialist. Exams may be performed more often than once a year if your provider decides they are medically necessary; otherwise, they are treated as preventive exams and covered on that basis.

Diabetes Self-Management Education Program

Benefits are paid in full for initial self-management education programs. Your provider can recommend a specialist or facility that provides these services. You must be enrolled in the Plan throughout the course of the program for benefits to be paid.

Weight Management  

The Plan provides nutritional counseling (up to two visits per calendar year) for treatment of obesity when medically necessary, as determined by your provider. Fasting and rapid weight loss programs are NOT covered.

As a Providence Health Plan member, you may be able to receive a discount on certain weight management classes. (Class availability may vary by geographic area. Call Providence Resource Line at 503-216-6595 or 800-562-8964 for specific information on classes.)

Women’s Health Care Services

Annual gynecological exams

Benefits for annual gynecological examinations include breast, pelvic and Pap examinations once every 12 months, or more frequently if your provider determines that they are necessary. Services for gynecological exams are covered benefits only when provided by a personal physician/provider or a women's health care provider.

Female members may receive preventive women’s care exams from their personal physician/provider or from any other qualified provider who specializes in women’s health care. Women’s health care providers include physicians specializing in obstetrics or gynecology, nurse practitioners, certified nurse midwives, or physician assistants specializing in women’s health care. Please note: Women’s health care services received from a naturopath or any other alternative care provider are not covered benefits.

Benefits also include follow-up exams for any medical conditions discovered during an annual gynecological exam that require additional treatment. Your follow-up visit co-payment/coinsurance may differ from your annual gynecological exam co-payment/coinsurance. See your plan’s Summary of Benefits for details on your co-payment/coinsurance information.

Mammograms

Annual benefits for mammograms are provided for women over 40 years of age. Mammograms are provided more frequently at the recommendation of your personal physician/provider or women’s health care provider.

Other Services

Counseling, exams, and some services for voluntary family planning are covered. Female members may receive these services from their personal physician/provider or any qualified women’s health care provider.  Contact your Customer Service Team or your local Human Resources department for detailed information.

If you receive office visit services from a participating personal physician/provider, you may be responsible for charges for services and supplies received from your personal physician/provider in addition to your member co-payment. For example – You see your personal physician/provider for an office surgery. You would pay your office visit co-payment and also may need to pay additional coinsurance for the office surgery and any medical supplies used for your surgery. See your plan’s Summary of Benefits for details.

Office visits & office surgery

For covered services, the Plan pays the balance in full after you pay your member co-payment/coinsurance. Your Summary of Benefits lists your co-payment/coinsurance information for various types of office visits.

If you are unable to keep a scheduled office appointment with your provider, please try to notify that office in advance. If not, you may be charged for the missed appointment. The In-Network Plan will not cover this expense.

Inpatient hospital visits

Provider visits in the hospital for approved hospitalization, including skilled nursing facilities, are covered.

Surgery and anesthesia

The Plan will cover provider charges for medically necessary surgery. This may include the fees of a surgeon, an assistant surgeon(s) and an anesthesiologist or registered nurse anesthetist. Your provider and/or the Plan will arrange and prior authorize your surgery. (If you are receiving these services from a non-participating provider, you are responsible for making sure the services are prior authorized by the Plan.)

Some surgical procedures are covered by the Plan only when performed on an outpatient basis. Your provider and/or the Plan will tell you in advance if your procedure is an outpatient surgery.

Allergy shots or injections

Allergy shots or injections are covered. Your member coinsurance for allergy shots is listed on your Summary of Benefits.

Hospital Services

Hospital services are covered, as stated on your Summary of Benefits. The Plan may require that you obtain a second opinion for some elective procedures. If you do not obtain a second opinion when requested, the Plan will not prior authorize the services and you will be responsible for paying for all of the services you receive.

Covered services do NOT include care received that consists primarily of:

• Room and board and supervisory or custodial services.
• Personal hygiene and other forms of self-care.
• Non-skilled care for senile deterioration, mental deficiency or mental retardation.

In all cases the following are specifically excluded from the hospital and skilled nursing facility benefit:

• Private duty nursing or a private room unless prescribed as medically necessary.
• Take-home medications, supplies and equipment.
• Personal items such as telephone, radio, television and guest meals.

Inpatient acute care

Using participating providers: When your provider and the Plan determine you need hospitalization, arrangements will be made for you to be admitted to a participating hospital.

Enrolled Out-of-Area Dependents/Subscribers: You are responsible for making sure inpatient hospitalization services are prior authorized by the Plan before receiving this care from a non-participating hospital.

The Plan employs professional clinical staff who may review services you receive in the hospital. They may review your care to determine medical necessity, to make sure that you had quality care and to ensure that you will have proper follow-up care.

Your provider will determine your medically appropriate length of stay. If you choose to stay in the hospital longer than your physician advises, you will be responsible for the cost of additional days in the hospital.

Inpatient rehabilitative care

Inpatient rehabilitative care is covered. This applies when you need a full rehabilitation team approach and the services can be provided to you only as an inpatient. These services must be part of your provider’s treatment program to improve lost function after an illness or an injury. If you are hospitalized when rehabilitative services begin, rehabilitative benefits will begin on the day treatment becomes primarily rehabilitative. Inpatient rehabilitative care is limited to 30 days per calendar year as stated on your Summary of Benefits.

Enrolled Out-of-Area Dependents/Subscribers: You are responsible for making sure inpatient rehabilitation services are prior authorized by the Plan before receiving this care from a non-participating hospital.

Skilled nursing facility

Skilled nursing facility services are covered when 24-hour skilled or subacute care is required and cannot adequately be provided through a home health program. Only medically necessary services are covered. The Plan may determine that your care needs are better served by transferring you from the hospital to a skilled nursing facility and reserves the right to make such a transfer. Services must be prescribed by your provider and prior authorized by the Plan. The Plan will cover up to 60 days of medically necessary care per calendar year as stated on your Summary of Benefits.

Enrolled Out-of-Area Dependents/Subscribers: You are responsible for making sure skilled nursing facility services are prior authorized by the Plan before receiving this care from a non-participating hospital.

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Maternity Services

Selecting a physician or provider

The Plan covers comprehensive maternity care. Women may go to their personal physician/provider or a women’s health care provider of their choice for obstetric care once pregnancy has been diagnosed. Women’s health care providers include physicians specializing in obstetrics, some personal physicians/ providers (if they provide obstetric services), nurse practitioners, certified nurse midwives or physician assistants specializing in women’s health care.

Covered services

• Prenatal care by your physician, provider or certified nurse midwife.
• Birth at an approved facility.
• Postnatal care, including complications of pregnancy and birth.
• Newborn nursery care.
• Emergency treatment for complications of pregnancy and unexpected pre-term birth outside the service area.

The following services are NOT covered:

• Home births. 
• Services of a lay midwife.

Length of hospital stay

You will not be discharged from the hospital sooner than 48 hours after a vaginal delivery or 96 hours after a caesarean delivery, unless you choose to be. You and your physician/provider will determine the length of your hospital stay and follow-up care based on accepted medical practice.

Newborn coverage

Select a family practitioner or pediatrician (personal physician/provider) for your baby. As soon as possible after delivery, add your newborn to your In-Network Plan coverage by contacting your employer and/or your Customer Service Team. Your baby is covered by the In-Network Plan for only 31 days after birth unless we receive a completed enrollment form from you or your employer within 60 days. See "Newly-acquired dependents," section for additional information.

Maternity support services

Members may attend a class to prepare for childbirth. The classes are held at participating hospitals. Call your Customer Service Team for information on payment coverage for these classes. Classes may vary by geographic area. See "Health Education" section, for additional information. In addition, members with high-risk pregnancies may receive support services through care or case management. A care manager may be a social worker and/or a registered nurse.

Infertility services

Services for the treatment of infertility are covered the same as relevant services as listed on your Summary of Benefits. You must see a participating provider for services to be covered. (Enrolled Out-of-Area Dependents/Subscribers may use a non-participating provider for these services.)

Covered services are limited to: Diagnostic testing and associated office visits to determine the cause of infertility. This includes the physical examination, related laboratory testing, instruction, and medical/surgical procedures when performed for the sole purpose of diagnosing an infertile state. Diagnostic services for infertility include, but are not limited to hysterosalpingogram, laparoscopy and pelvic ultrasound.

All other infertility services are not covered.

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Medical and Diabetes Supplies, Durable Medical Equipment, Appliances, Prosthetic Devices

The Plan will provide coverage for the purchase or rental of Plan-approved medical supplies/devices, prosthetic devices and durable medical equipment, (DME). All supplies/equipment/devices must be required for the standard, treatment of the illness or injury.

All Plan-approved supplies/equipment/devices must be medically necessary and are limited to the most cost-effective equipment. The Plan may authorize the purchase of an item if we determine the cost of purchasing an item would be less than the overall rental of the item. Supplies/equipment/devices must be prescribed by your qualified practitioner.

The reasonable cost of repairing an item is covered as long as this cost does not exceed the purchase of a new piece of equipment or device. Items that are replaced due to loss or negligence are not covered. Items that are replaced due to the availability of a newer or more efficient model are not covered unless the Plan determines otherwise. Repair or replacement is covered if due to normal growth processes or to a change in your physical condition due to illness or bodily injury.

Participating Medical Supply/Equipment Providers 

Providence Home Services coordinates all home medical equipment covered by the Plan through its home services network. In most instances home health equipment purchases will be coordinated with Providence Home Services by your personal physician/provider or other participating provider. If you need to purchase home medical equipment on your own, you must call Providence Home Services at 1-800-531-9754.

Exceptions:

• Some covered equipment, supplies and appliances dispensed during an office or hospital visit can still be billed by your provider directly to Providence Health Plan without going through Providence Home Services.
• You can purchase diabetes supplies through participating pharmacies and other participating vendors who sell these supplies rather than buying them through Providence Home Services.

The Plan covers:

• Casts, braces and supportive devices – Covered when used in the treatment of medical or surgical conditions in acute or convalescent stages or as immediate post-surgical care.
• Initial and replacement contact lenses, intraocular lenses, prescription lenses or standard frame glasses – Covered when required as a result of injury, illness or surgery, such as cataract, corneal transplant surgery or for the treatment of keratoconus.
• Rental of oxygen units used in the home – Covered for members with significant hypoxemia who are unresponsive to other forms of treatment. The benefit is limited to three months from the initial date of service unless there is clinical evidence of the need to continue.
• Orthotics – Limited to a maximum benefit of $200 every 24 months. Orthotics do not include prosthetic devices or childhood braces.
• Prosthetic devices – Covered supplies include prosthetic devices such as artificial limbs, breast implants following mastectomy, and artificial eyes.
• Maxillofacial prosthetic devices – Covered when considered medically necessary for the restoration and management of head and facial structures that cannot be replaced by living tissue. When head and facial structures are impaired due to disease, trauma, or developmental deformity. The devices must be needed to control or eliminate infection and pain and restore facial configuration and function.
• Medical devices surgically implanted in a body cavity to replace or aid the function of an internal organ.
• Medically necessary medical foods – Covered for supplementation or dietary replacement, including non-prescription elemental enteral formula for home use, when determined to be medically necessary for the treatment of severe intestinal malabsorption. Approval of these services will be based on criteria established by the In-Network Plan and in accordance with regulatory requirements. Medical foods are defined as foods that are formulated to be consumed or administered enterally under strict medical supervision for the treatment of inborn errors of metabolism including, but not limited to: phenylketonuria (PKU); homocystinuria, citrullinernia, maple syrup disease; and pyruvate dehydrogenase deficiency.
• Other medically necessary supplies – Covered when ordered by a qualified practitioner, including, but not limited to, ostomy supplies, prescribed needles, syringes and blood sugar check strips. You can purchase diabetes supplies through PeaceHealth pharmacies in addition to purchasing them through Providence Home Services or your provider's office.
• Durable medical equipment (DME) – Covered for rental of crutches, wheelchairs, hospital beds, or other therapeutic equipment when prescribed by a qualified practitioner, subject to the Plan’s durable medical equipment definition. Covered services for DME do not include items that are primarily and customarily used for a non-medical purpose or which are used for environmental control or enhancement (whether or not prescribed by a physician).

No other medical supplies, devices, prosthetic devices or DME are covered.

Emergent/Urgent & Ambulance Services

Emergency services

Please see Emergency and Urgent Care

Urgent care services

Please see Emergency and Urgent Care

Ambulance

• The following certified ambulance services are covered when medically necessary:
• Ground ambulance transportation.
• Air ambulance services are covered when prior authorized by the Plan. Exception: Prior authorization is not required for medical emergencies.
• Out-of-area ambulance services to provide transportation to the nearest facility, or to a facility specified by the Plan.

We do NOT cover care cars, other medical transportation vehicles and other non-emergency medical transportation.

Diagnostic x-ray and laboratory services

The Plan pays for inpatient and outpatient diagnostic pathology (laboratory), radiology (x-ray) tests and diagnostic procedures that include EMG, nerve conduction studies, nuclear medicine, pulmonary function, electrophysiology and other medically necessary diagnostic procedures when ordered by a qualified provider.

Outpatient rehabilitative services

Short-term outpatient rehabilitative services are covered up to 30 visits per calendar year. Therapy is provided by physicians and/or licensed or registered therapists to restore or improve function due to illness or injury. Benefits are limited to covered services that can be expected to result in the significant improvement of your condition. Covered services are for outpatient physical, occupational and speech therapy.

The treatment must be part of a written treatment plan prescribed by a qualified provider. The Plan will NOT provide benefits for exercise programs; Rolfing, polarity therapy and similar therapies; and growth and cognitive therapies.

Outpatient surgery, chemotherapy & radiation therapy benefits are provided as shown on your Summary of Benefits and include outpatient services at a hospital or other facility. Covered services include, but are not limited to, services for a surgical procedure and regularly scheduled therapy such as chemotherapy, inhalation therapy, or radiation therapy as ordered by a qualified practitioner. The Plan may require that you obtain a second opinion for some elective procedures. If you do not obtain a second opinion when requested, we will not prior authorize the services and you will be fully responsible for payment.

Non-surgical temporomandibular joint (TMJ) services

Benefits are provided for non-surgical TMJ services from a participating provider as shown on your Summary of Benefits. In-Network Plan enrolled Out-of-Area Dependents/Subscribers may receive covered services from a non-participating provider.

All covered non-surgical TMJ services must be prior authorized by the Plan. Covered services include:

• A diagnostic examination including a history, physical examination and range of motion measurements as necessary.
• Diagnostic x-rays.
• Physical therapy of necessary frequency and duration, limited to 20 visits per calendar year.
• Therapeutic injections.
• Therapy utilizing an appliance/splint that does not permanently alter tooth position, jaw position or bite. Benefits for this therapy will be based on the use of a single appliance/splint, regardless of the number of appliances/splints used in treatment. The benefit for the appliance/splint therapy will include an allowance for diagnostic services, office visits and adjustments.

Covered services do NOT include dental or orthodontia services.

Treatment of specified dental services and restoration of head and facial structures

Covered services include restoration and management of head and facial structures, including teeth, dental implants and bridges, that cannot be replaced with living tissue and that are impaired because of trauma, disease or birth or development deformities. Benefits are covered as those services listed on your Summary of Benefits based upon the type of services received.

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Conditions for receiving this benefit:

• All treatment, except emergency services, must be prior authorized by the Plan.
• Conditions related to trauma must be diagnosed within six months of injury and treatment must begin within twelve months of the injury.

Covered services do NOT include:

• Cosmetic services.
• Services rendered to improve a condition that falls within the normal range of such conditions.
• Orthodontia.
• Services to treat tooth decay, periodontal conditions and deficiencies in dental hygiene. Removal of impacted teeth.
• The making or repairing of dentures.
• Orthognathic surgery to shorten or lengthen the upper or lower jaw, unless related to a traumatic injury or to a neoplastic or degenerative disease.
• Services to treat TMJ joint disorder, except as specified in the covered TMJ services section above.

Outpatient hospitalization and anesthesia for dental services

Benefits for outpatient hospitalization and anesthesia for dental services are covered the same as relevant services listed on your Summary of Benefits.

Services must be prior authorized by the Plan and are only provided for members with complicating medical conditions. Examples of these conditions include, but are not limited to, mental handicaps, physical disabilities, or a combination of medical conditions or disabilities that cannot be managed safely and efficiently in a dental office.

All other dental services are excluded.

Home health care

Home health visits are covered as shown on your Summary of Benefits. To be a covered benefit, a home health care provider must provide services at your home under a home health care treatment plan. Each visit by a person providing services under a home health care treatment plan, or each visit to evaluate the need for or development of a plan, is considered to be one home health care visit. Up to four consecutive hours in a 24-hour period of home health care service is considered to be one home health care visit. A home health care visit of more than four hours is considered one visit for every four hours or part thereof.

For home health care to be a covered benefit, your qualified provider needs to certify that the home health care services will be provided or coordinated by a state-licensed or Medicare-certified home health agency or certified rehabilitation agency. If you were hospitalized immediately prior to the start of your home health care, the home health plan must be initially approved by the same qualified practitioner who was the primary provider of the services you received during your hospitalization.

Home health care benefits do NOT include:

• Charges for mileage or travel time to and from your home.
• Wage or shift differentials for home health providers.
• Charges for supervision of home health providers.
• Services that consist principally of custodial care including, but not limited to, care for senile deterioration, mental deficiency, mental retardation or mental illness, or care of a chronic or congenital condition on a long-term basis.
• Services provided that are not otherwise covered under the Plan.

Hospice care

Covered hospice care services are provided, as stated on your Summary of Benefits, for members who have a terminal illness and are expected to live six months or less. This determination needs to be certified by your qualified provider and determined by the Plan to be medically necessary. Hospice care services are limited to medical care that provides comfort and support for a dying person, usually in his or her home, but does not effect a cure. Covered services provided must be reasonable and necessary for the condition and symptoms being treated.

When the above criteria are met, the Plan will provide benefits for a full range of covered services that a certified hospice care program is required to include.

Covered services include:

• Nursing care provided by or under the supervision of a registered nurse.
• Medical social services provided by a medical social worker who is working under the direction of a physician. This may include counseling for the purpose of helping the patient and caregivers adjust to the approaching death.
• Services provided by your qualified practitioner or a physician associated with the hospice program
• Durable medical equipment, medical supplies and devices, including medications used primarily for the relief of pain and control of symptoms related to the terminal illness.
• Home health aide services for personal care, maintenance of a safe and healthy environment and general support for the goals of the plan of care; including a maximum of 120 hours of respite care to the primary care giver during a three-month period.
• Rehabilitation therapies provided for purposes of symptom control or to enable the patient to maintain activities of daily living and basic functional skills.
• Continuous home care during a period of crisis in which the patient requires skilled intervention to achieve palliation or management of acute medical symptoms.
• Benefits for hospice care services may be extended an additional six months in cases where a member is facing imminent death, or is entering a remission, and the member’s condition has been certified in writing by the attending physician.

No other services are covered under the hospice care benefit.

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Podiatry/foot services

Covered services include the services provided by a podiatrist or other qualified practitioner and are covered as stated on your Summary of Benefits under the Physician/Provider Services section. Covered services include, but are not limited to, the fitting and follow-up exam for orthotics when required as a result of surgery, congenital defect or diabetes. Orthotics are covered as stated under "Orthotics," section.

Covered services do NOT include routine foot care and the removal of corns or calluses, unless you have diabetes.

Reconstructive breast surgery

Medically necessary reconstructive breast surgery following a mastectomy is a covered benefit. This includes reconstruction of the involved breast following a mastectomy due to disease, illness or injury; surgery and construction of the other breast to produce a symmetrical appearance; and prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas.

Cosmetic/reconstructive surgery

Reconstructive surgery that is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part is covered. The Plan also will provide covered services for the treatment of congenital disease or anomaly of a covered dependent child that has resulted in a defect. Benefits are covered as those services listed on your Summary of Benefits based upon the type of services received. All covered services must be prior authorized by the Plan.

Not covered: All other forms of cosmetic surgery, such as services and supplies that are applied to normal structures of the body for the purpose of improving or changing appearance or enhancing self-esteem, are excluded.

Inborn errors of metabolism

Covered services include services received for diagnosing, monitoring and controlling inborn errors of metabolism, including PKU, that involve amino acid, carbohydrate and fat metabolism. Covered services include clinical visits, biochemical analysis and medical foods used in the treatment of such disorders. See "Medically Necessary Medical Foods," for coverage information on medical food supplies. Coverage is provided as shown on your Summary of Benefits based upon the type of services received.

Human organ/tissue transplants

Benefits for human organ and tissue transplants include covered services to the extent shown on your Summary of Benefits that are not experimental, investigational or for research purposes.

Covered services consist of all phases of prior authorized treatment:

1. Evaluation;
2. Pre-transplant care;
3. Transplant and any donor covered services; and
4. Follow-up treatment, including any prescription drugs received relating to the transplant, are covered when provided within two years of the transplant procedure.

Covered services incurred by a live donor are provided under this benefit as though the donor’s expense is the expense of the member when both of the following apply:

• The recipient is an the In-Network Plan member; and
• The services are not provided by any other plan.

Covered services are only provided when:

• Prior authorization is received from the Plan;
• Services are provided at a participating facility approved by the Plan (generally, Open Network Plus Plan members must use their In-Plan benefit only for these services) (clarification); and
• The procedure is in accordance with standard medical practice in the judgment of the Plan.

Covered human organ/tissue transplants include, but are not limited to, the following when medically necessary and approved in advance by the Plan:

• Kidney; corneal; heart; lung; liver; and bone marrow transplants and combinations thereof; pediatric liver transplants, including the treatment of children with biliary atresia and other rare congenital abnormalities;
• Bone marrow transplants under the following circumstances:
  • Aplastic anemia;
  • Leukemia; and
  • Other diseases in accordance with standard medical practice in the judgment of the In-Network Plan.

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The following organ transplant covered services apply to the transplant benefit:

• All covered services related to the transplant surgery before the actual surgery, including high dosage chemotherapy for autologous bone marrow transplant for the treatment of breast cancer;
• All resultant covered services related to the transplant after the surgery. The term "resultant covered services" includes, but is not limited to, medical services, medical supplies, inpatient and outpatient drugs and medications, diagnostic modalities, prosthesis and therapy. Benefits for FDA-approved outpatient immunosuppressive drugs furnished to an organ transplant patient whose transplant was covered by the Plan are provided;
• Treatment of conditions resulting from the transplant; and  
• Donor’s initial medical evaluation and surgical expenses related to actual harvesting of the organ, as well as the cost of treating complications directly resulting from the surgery, but only if the recipient is a member and the donor is not eligible for coverage under any other health plan or government funding program.

Reasonable and necessary transportation expenses related to covered transplant services are covered subject to the following:

• The travel expense reimbursement is limited to a maximum of $5,000 per transplant.
• The benefit includes expenses of the member receiving the transplant and one companion, or two companions if the member receiving the transplant is a minor.
• All transportation expenses must be prior authorized by the Plan.

Chiropractic care coverage

Your In-Network Plan Chiropractic Benefit provides coverage for chiropractic visits and treatment.

How to access services

When you feel that you need services from an alternative care provider, you have two choices: 1) See one of the participating doctors of chiropractic medicine listed in the Providence Health Plan Chiropractic Provider List. . When you see a participating provider, you will be taking advantage of Providence Health Plan’s discounted provider rate. This means you will be able to get more services covered before you reach your annual benefit maximum; or 2) See a non-participating licensed doctor of chiropractic medicine. When you see a non-participating provider, however, costs for services received usually will be more and subsequently you may reach your annual benefit maximum faster than when you use participating providers. You do not need to meet any applicable medical plan deductibles before receiving this benefit. 

Covered benefits

• Covered chiropractic services must be consistent with current procedural terminology (CPT) guidelines and are limited to the following, as deemed medically necessary by Providence Health Plan or its authorizing agent:
• Initial evaluation visit for each diagnosis or injury.
• Chiropractic treatment such as manipulation for neuromusculoskeletal disorders.
• Related diagnostic laboratory or x-ray services.
• Physical therapy services only when associated with spinal manipulation and provided by a participating chiropractic physician.
• A $10 co-payment will be charged at the time the service is rendered. This co-payment is not applied toward your plan’s medical annual out-of-pocket maximums or any applicable deductibles. You do not need to meet any applicable medical plan deductibles before receiving this benefit. The maximum chiropractic benefit per calendar year is $1,500 per member.
• Enrolled Out-of-Area Dependents of In-area subscribers and Out-of-Area Subscribers only: Please refer to your Member Handbook and Out-of-Area Summary of Benefits for Out-of-Area Member information.

Exclusions and Limitations

• Treatment of alcohol, drug or chemical dependency in a specialized inpatient or residential facility.
• Behavioral training and modification including, but not limited to, biofeedback, hypnotherapy, play therapy and sleep therapy.
• Cosmetics, dietary supplements, health or beauty aids.
• Services furnished by a facility that is primarily for rest, custodial care, a place for the aged, a nursing home or any facility of like character.
• Devices or appliances, durable medical equipment, supplies, appliances or prosthetics.
• Drugs and medications, prescription or non-prescription, including vitamins, minerals, nutritional or dietary supplements, or any other supply or product whether or not prescribed or recommended by the member's participating chiropractic physician.
• Services provided in the emergency room.
• Exercise, recreation, hygienic and beautification classes and equipment.
• Services considered experimental or investigational.
• Services that exceed the limitations or fail to meet the conditions of covered services.
• Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT Scan) diagnostic services. Please see your plan’s medical summary of benefits and member handbook for coverage of diagnostic services. Charges for these services do not apply toward the alternative care annual benefit maximum.
• Services deemed not medically necessary by Providence Health Plan or its authorizing agent.
• Military service connected disability care for which the treatment is legally entitled through a federal government facility
• Services not delivered by a participating provider.
• Services and charges for the condition under treatment from the time the patient refuses, for personal reasons, to accept a recommended treatment or procedure after being advised that the treating participating health care provider believes no professionally acceptable alternative exists.
• Personal or comfort items; environmental enhancements; modifications to dwellings, property or motor vehicles; adaptive equipment and training in the use of equipment; personal lodging, travel expenses or meals.
• Physical exams; vocational rehabilitation; workers’ compensation illnesses or injuries; evaluations and reports such as those for employment, licensing, school, sports, premarital or required for court proceedings.
• Physical therapy, unless associated with spinal manipulation and provided by the member's participating chiropractic physician.
• Services rendered prior to the effective date of coverage.
• Public facility care in which services or care are required by federal, state or local law.
• Self-help or educational programs including any diagnostic testing related to such services.
• Thermography.
• Transportation services (including ambulance and care cars).
• Weight control supplies or products.

Arranging mental health or chemical dependency services

Non–emergency outpatient, inpatient, residential, and day treatment mental health and chemical dependency services are covered benefits only when prior authorized. Please contact the Plan’s authorizing agent, Mental Health Match at 1-800-457-3798 or 541-744-0828. Mental Health Match and your qualified practitioner will coordinate your care.

For emergency mental health or chemical dependency services, go directly to a hospital emergency room. You do not need prior authorization for emergency treatment. You, or a relative, should notify the Plan within 48 hours of emergency treatment, or as soon as reasonably possible.

All treatment is monitored for medical necessity by Mental Health Match. Prior authorization of mental health services is based on criteria established by the International Classification of Diseases (ICD) and the latest version of the Diagnostic and Statistical Manual of Disorders (DSM Manual). A copy of this criteria can be obtained by calling Mental Health Match at 1-800-457-3798 or 541-744-0828.

Mental health services

Benefits are limited to covered services provided in the least costly treatment setting which, in the judgment of Mental Health Match, is medically necessary for the individual patient’s condition.

Covered services:

• Outpatient diagnostic evaluation and mental health treatment including individual and group therapy.
• Inpatient, residential and day or partial hospitalization for the treatment of mental disorders. These services must be obtained at a treatment facility approved by the Plan’s authorizing agent, Mental Health Match.

Chemical dependency services

Benefits include covered services necessary for the diagnosis and treatment of chemical dependency (drug and alcohol treatment), including detoxification. Treatment involving the use of methadone is covered only when such treatment is part of a medically supervised treatment program approved by Mental Health Match.

Covered services:

• Outpatient diagnosis and treatment for chemical dependency including, detoxification. Treatment includes individual and group therapy.
• Inpatient, residential and day or partial hospitalization for the treatment of chemical dependency disorders. These services must be obtained at a treatment facility approved by Mental Health Match.

Medically necessary detoxification 

Medically necessary detoxification will be treated as an emergency medical condition when members are not enrolled in other chemical dependency treatment programs at the time services are received. Members do not need prior authorization for this emergency treatment; however, Mental Health Match must be notified within 48 hours following the onset of treatment, or as soon as reasonably possible, in order for coverage to continue. If a member is to be transferred to a participating provider for continued inpatient care, the cost of medically necessary transportation will be covered. Continuing or follow-up care is not a covered service unless prior authorized by Mental Health Match.

Benefit limits for covered mental health and chemical dependency services

Covered mental health services have benefit limits or maximums that comply with federal and state law. Benefit limitations are for a period of two calendar years. Limits begin to accumulate on January 1, 2001 and will continue to accumulate for 24 months before renewing on January 1, 2003, regardless of when you begin receiving covered benefits. After January 1, 2003, benefit limits will renew on January 1 of all odd-numbered years (i.e., 2005, 2007, 2009). Please refer to your Summary of Benefits for more detailed information on your benefit limitations.

When you need to access both mental health and chemical dependency covered services, covered services for mental health will be applied to the mental health benefit limits and covered services for chemical dependency will be applied to the chemical dependency benefit limits up to the benefit maximums for each category of services as stated on your Summary of Benefits.

Click here for information regarding your Prescription Drug Benefit

General Exclusions and Limitations

In addition to those services listed as not covered in the "Benefits" section, the following are not covered or have coverage limitations as noted.

General Exclusions:

• Services that are not provided.

• Services received before your effective date of coverage.

• Services that are not a covered service or relate to complications resulting from a non-covered service.

• Services that are not furnished by a qualified practitioner or qualified treatment facility.

• Services provided by or payable under any plan or law through a government or any political subdivision, unless prohibited by law.

• Services provided while you are confined in a hospital or institution owned or operated by the United States Government or any of its agencies, except to the extent provided by 38 U. S. C. 1729 as it relates to non-military services provided at a Veterans Administration hospital or facility.

• Services provided by a person who ordinarily resides in your home or who is a member of your immediate family (parent, spouse, sibling or child).

• Services provided for convenience, educational or vocational purposes including, but not limited to, videos and books, educational programs to which drivers are referred by the judicial system and volunteer mutual support groups.

• Services performed in association with a service that is not covered under the Plan.

• Services provided in an institution for the developmentally disabled, except while in an acute care hospital for conditions other than mental retardation.

• Services provided for treatment or testing required by a third party or court of law which are not medically necessary.

• Services that are experimental, investigational or for research purposes.

• Services that are determined by the In-Network Plan not to be medically necessary for diagnosis and treatment of a bodily injury or illness.

• Services and supplies which relate to any condition sustained as a result of engagement in an illegal occupation, the commission or attempted commission of an assault or other illegal act, a civil revolution or riot, duty as a member of the armed forces of any state or country, or a war or act of war which is declared or undeclared.

• Services for which no charge is made or you would not be required to pay if you did not have the In-Network Plan coverage.

• Services and supplies received by a qualified member under the Oregon Death with Dignity Act.

• Payment or expense coverage is provided under a motor vehicle insurance policy, as required by Oregon state mandated minimum personal injury protection (PIP) limits.

• Services and supplies provided for any bodily injury or illness that is sustained by an eligible employee or family member that arises out of, or as the result of, any work for wage or profit when coverage under any Workers' Compensation Act or similar law is required for the eligible employee or family member. This exclusion does not apply to Plan members who are exempt under any Workers’ Compensation Act or similar law.

• Charges in excess of the usual, customary and reasonable (UCR) charge as defined by the In-Network Plan.

• Services of licensed acupuncturists, a physician performing acupuncture services, naturopathic physicians and chiropractic physicians.
• Services of homeopaths, faith healers, or lay midwives.
• Wage or shift differentials or charges for supervision of home health providers.

• Sexual disorders or dysfunctions regardless of gender, including, but not limited to, services, surgery, prescription drugs; and services, supplies and medications related to preparation for sex change operations and medical or psychological counseling or hormonal therapy in preparation for, or subsequent to, any such procedure.
• Termination of pregnancy, unless there is a severe threat to the mother, or if the life of the fetus cannot be sustained.
• Reversal of voluntary sterilization.
• Norplant, including all services for insertion.
• Condoms.
• All services for non-member surrogate mothers.
• All services associated with surrogate parenting, including infertility testing and treatment.
• Home births and all related services.
• Services provided in a premenstrual syndrome clinic or holistic medicine clinic.
• All infertility services except for diagnostic testing and associated office visits to determine the cause of infertility.

• Surgical procedures which alter the refractive character of the eye, including, but not limited to laser eye surgery, radial keratotomy, myopic keratomelelusis and other surgical procedures of the refractive keratoplasty type, the purpose of which is to cure or reduce myopia, hyperopia or astigmatism.
• Services for routine eye and vision care, routine vision exams, refractive disorders, except as stated under "Children’s Vision and Hearing Screenings," section.
• Eyeglass frames and lenses, contact lenses and other routine vision supplies, except as stated under "Initial and Replacement Contact Lenses, Intraocular Lenses, Prescription Lenses or Standard Frame Glasses," section.
• Orthoptics and vision training.

• Oral surgery (non-dental or dental) or other dental services (all procedures involving the teeth; wisdom teeth; areas surrounding the teeth), except as approved by the Providence Health Plan and described under "Treatment of Specified Dental Services and Restoration of Head and Facial Structures," section.
• Services for non-surgical temporomandibular joint syndrome (TMJ) and orthognathic surgery, except as approved by the Providence Health Plan and described under "Non-surgical Temporomandibular Joint (TMJ) Services," section. Prior authorization by the Plan is required for these services to be covered.
• Dentures and orthodontia.

• Routine foot care, such as removal of corns and calluses, except for diabetes.
• Services for insoles, arch supports, heel wedges, lifts and orthopedic shoes. Covered Services for orthotics are described under "Orthotics," section.

Exclusions that apply to mental health and chemical dependency:

• Conditions that are not responsive to therapeutic management after a diagnosis is made by a physician who has treated or examined the patient, except when the treatment or services provided are effective in maintaining existing functionality or preventing a decline in functionality.
• Conditions other than mental disorders specified in the current edition of the Diagnostic and Statistical Manual of Disorders (DSM).
• Services provided under a court order or as a condition of parole, probation or instead of incarceration.
• Services related to marriage counseling, personal growth services such as assertiveness training or consciousness raising, mental retardation and learning disabilities.
• Any mental health service or supply related to the condition of autism or Asperger disorder.
• Counseling related to family, marriage, sex and career, in the absence of illness.
• Vocational, pastoral or spiritual counseling.
• Dance, poetry, music or art therapy, except as part of a treatment program in an inpatient setting.
• Non-organic therapies including, but not limited to, bioenergetics therapy, confrontation therapy, crystal healing therapy, educational remediation, EMDR, guided imagery, marathon therapy, primal therapy, rolfing, sensitivity training, training psychoanalysis, transcendental mediation, and Z therapy.
• Organic therapies including, but not limited to, aversion therapy, carbon dioxide therapy, environmental ecological treatment or remedies, herbal therapies, hemodialysis for schizophrenia, vitamin or orthomolecular therapy, narcotherapy with LSD, and sedative action electrostimulation therapy.
• Treatments which do not meet the national standards for mental health professional practice.

• Custodial care.
• Transplants, except as described under "Human organ/tissue Transplants," section.
• Services for durable medical equipment (DME), medical supplies/devices and prosthetic devices except as described under "Medical and Diabetes Supplies, Durable Medical Equipment, Appliances, Prosthetic Devices," section.
• Any drug, medicine, or device that does not have the United States Food and Drug Administration formal market approval through a New Drug Application or Pre-market Approval.
• Charges for services that are primarily and customarily used for a non-medical purpose or used for environmental control or enhancement (whether or not prescribed by a physician) including, but not limited to, air conditioners, air purifiers, vacuum cleaners, motorized transportation equipment, escalators, elevators, tanning beds, ramps, waterbeds, hypoallergenic mattresses, cervical pillows, swimming pools, whirlpools, spas, exercise equipment, gravity lumbar reduction chairs, home blood pressure kits, personal computers and related equipment or other similar items or equipment.
• Physical therapy and rehabilitation services, including exercise programs, Rolfing, polarity therapy and similar therapies, and growth and cognitive therapies, except as described under "Inpatient Rehabilitation Care," section and "Outpatient Rehabilitative Services," section.
• "Telephone visits" by a physician or "environment intervention" or "consultation" by telephone for which a charge is made to the patient. "Get acquainted" visits without physical assessment or diagnostic or therapeutic intervention provided and treatment sessions by computer Internet service.
• Non-emergency medical transportation.
• Therapy and testing for treatment of allergies including, but not limited to, services related to clinical ecology, environmental allergy and allergic immune system dysregulation and sublingual antigen(s), extracts, neutralization tests and/or treatment UNLESS such therapy or testing is approved by the American Academy of Allergy and Immunology or the Department of Health and Human Services or any of its offices or agencies.
• All services and supplies related to the treatment of obesity as a primary or secondary (co-morbid) condition, except as stated as covered in the bullet below and under "Weight Management," section.
• Services for dietary therapy including medically supervised formula weight-loss programs or unsupervised self-managed programs. Over-the-counter weight loss formulas are not covered; however, a Member may be referred from a qualified provider for two visits per calendar year for nutritional counseling, see "Weight Management," section.
• Communication charges and lodging accommodations.
• Transportation or travel time, except as described under "Benefits," and with the In-Network Plan’s prior authorization.
• Charges for health clubs or health spas, aerobic and strength conditioning, work-hardening programs, and all related material and products for these programs.
• Medications, drugs or hormones to stimulate growth, except for children through age 18 when diagnosis of growth hormone deficiency is laboratory confirmed, and for adults only when they are being treated for pituitary destruction. Covered services are limited and subject to prior authorization and may be accessed through the prescription drug benefit or through your provider.
• Massage therapy.
• Light therapy for seasonal affective disorder, including equipment.
• Hearing aids, including all services related to the examination and fitting of the hearing aids. Routine hearing exams, except as stated under "Children’s Vision and Hearing Screenings," section.
• Any vitamins, dietary supplements, and other non-prescription supplements, except when prescribed as part of a nutrition therapy plan for the treatment of diabetes.
• Services and supplies in connection with the diagnosis and treatment of learning disabilities.
• Services for the treatment of developmental delay.
• Services for genetic testing in the absence of disease.
• Services to modify the use of tobacco and nicotine, except as described in the wellness program materials included in your member material packet.
• Services for cosmetic services including supplies and drugs, except as approved by the In-Network Plan and described under "Cosmetic/reconstructive Surgery," section.
• Services for routine physical examinations for insurance, employment, licensing purposes, or solely for the purpose of participating in camps, sports activities, recreation programs, college entrance or for the purpose of traveling or obtaining a passport for foreign travel.
• Services for immunizations or vaccinations for employment, licensing, passports, travel purposes, and high risk occupations.

Benefits From Other Sources

Third party liability (subrogation)

Sometimes, a third party pays for a member’s medical expenses because the member was injured by them. For example, if you are hurt in a store and the owner was at fault for your injury, the owner or owner’s insurance may be responsible for your medical care and services related to your injury.

In these types of situations, your In-Network Plan coverage is secondary. We need detailed information from you whenever you use your Plan benefits because of:

• a workplace accident, injury or illness;
• an injury or illness that may result in a lawsuit, or for which you expect to receive a settlement;
• a motor vehicle accident.

Recovering money from a third party

The In-Network Plan may recover money from a third party, usually an insurance carrier, who may be responsible for paying for your treatment for an illness or injury. The Providence Health Plan may sue in your name, if necessary.

By accepting membership in the In-Network Plan, you make an agreement with us – if you receive a settlement for an illness or injury, you must pay us back for the cost of your treatment.

Example: You are injured while on a weekend visit to a coastal resort. You sue, and are awarded $7,500 plus attorney’s fees. Meanwhile, the In-Network Plan has paid a total of $6,000 for treatment of your injury, so you must reimburse us for $6,000 out of your settlement.

Before you accept any settlement, you must let us know the terms, and tell the third party that we have an interest in the settlement. If you have medical bills after your receive a settlement, we will not pay those bills until your settlement is exhausted.

Notification If you are using your In-Network Plan benefits for an illness or injury you think may be the responsibility of another party, notify us in writing as soon as possible. In addition, if we identify a claim that may be the responsibility of a third party, we will ask you for more information about how you were injured, and what you are doing to determine the legal liability of the third party who may be at fault.

We also will ask you to agree in writing to the following:

• Repay us for medical expenses that we paid related to your subrogated situation to the extent that the law allows.
• Include our claims paid for you in any claim you make against the party who injured you.
• Prorate any attorney fees that you spent in your recovery related to our repayment.

This Agreement requires that you cooperate with us so that we can recover the amount due to us by law.

Motor vehicle coverage

Oregon law requires motor vehicle liability policies to provide primary medical payment insurance. When coverage is available from motor vehicle liability insurance, the Plan will be entitled to recover the cost of services provided. Also, we will cover the cost of services in excess of those covered by the motor vehicle insurance per Plan guidelines. The In-Network Plan’s right to recover the amounts it pays is described above.

The Plan’s right to receive and release necessary information

The Plan may, with your written consent, release to, or obtain from any other insurer, organization or person, any necessary information we need to administer third party liability. To claim benefits from the Providence Health Plan, you will need to give us the necessary information for this purpose.

Sometimes you or your covered dependents are eligible for benefits under another medical insurance plan. If so, benefits for the In-Network Plan covered services will be coordinated with those from the other insurance plan. The In-Network Plan also coordinates benefits with Medicare. This is called coordination of benefits (COB).

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If you have other coverage in addition to your Providence Health Plan coverage, we recommend that you submit your claim to us and to each other insurer at the same time. By doing this, the proper coordinated benefits may be most quickly determined and paid.

COB is a way to figure out how much each health plan will pay when you have a claim. The total benefits you receive will not exceed the cost of services. One group plan always pays first (primary plan) and the other plan always pays second (secondary plan). Your primary plan will pay for your services under its policy’s terms first, and your secondary plan will pay any member out-of-pocket costs according to its terms. Remember, insurance carriers will pay only for those services which are covered in their plans.

Exception - If the primary insurance covered a service that the In-Network Plan as the secondary plan does not cover and you have savings in your COB benefit bank, we may pay for some of these costs, up to the savings limit and our allowable payable amounts. See "Benefits Bank for Coordination of Benefits," section.

You must inform the In-Network Plan of your coverage, or your dependent’s coverage, with other insurance plans. Periodically we will send you a questionnaire asking you to update your other coverage information. Please return this form to us promptly to ensure timely processing of your claims.

COB between insurance plans is required and governed by federal and state laws. The Plan will determine coordination of benefits using rules established by these laws to determine the responsibility of each plan

Following Plan rules COB benefits are provided only when you follow Plan procedures and requirements as stated in this handbook, regardless of whether the In-Network Plan is considered your primary or secondary plan.

Example: You are a In-Network Plan member and the In-Network Plan is your secondary plan. As a In-Network Plan member, you are required to use participating providers to receive covered services. If you do not see a participating provider for the services you receive, the In-Network Plan would not pay for any remaining balance owed by us as the secondary plan.

Determining primary and secondary plans

The following rules describe the order in which health plans generally provide benefits:

• First – When a plan does not have a provision for coordinating benefits, it is always considered the primary plan.
• Second – The plan in which you are a subscriber.
• Next – The plan in which you are a dependent.

The following rules apply to dependent children:

• If parents are not separated or divorced: The "birthday rule" applies. This rule states that the plan of the parent whose birthday comes first during the year is primary. However, some plans do not follow the birthday rule. In these cases, the rule of the other plan applies.
• If parents are separated or divorced: If a court order makes one parent responsible for paying the child’s health care costs, that parent’s plan is primary. If not, the plan of the parent with custody is primary. If the parent with custody remarries, the secondary plan will then be that of the stepparent. And the plan of the parent who does not have custody will pay third.

If the rules above do not apply, the plan that has covered you longest is the primary plan. However, this rule does not apply if you are covered as an employee who has been laid off or has retired, or as a dependent of that employee. In these cases, the plan covering you as an employee who has been laid off or has retired, or as a dependent of that employee, is the secondary plan. Both plans must follow this rule for it to apply.

If none of the above rules apply, the plan that has covered you longest is the primary plan.

Getting medical claims processed

If you are covered by more than one health plan, check with your physician or other health care provider’s office staff to find out how they handle insurance billing. Your provider’s office may have a policy of not billing a secondary insurance carrier, or the office may charge you an extra fee for billing both carriers.

Most health plans will send you an explanation of benefits (EOB) whenever a medical claim is processed. The EOB explains any amounts of charges that may be your responsibility. When your other health plan carrier pays first, send us the original bill with the EOB you have received from them. Usually, that is all we need to process your claim. When the In-Network Plan pays first, attach our EOB to your original bill and send these records to your other insurer. If you have not received an EOB from us, call your Customer Service Team and we will send one to you promptly.

Getting pharmacy claims processed

(Applicable only if your employer has purchased supplemental prescription drug coverage.) If you are covered by more than one plan for prescription drugs and the In-Network Plan is your secondary plan, then you will have to pay your primary plan’s copayment/ coinsurance to the pharmacy. Keep your itemized receipt of your copayment and send it to us. We will reimburse you the amount that we owe.

Benefits bank for coordination of benefits

When the In-Network Plan is the secondary plan, the amount of our payments for benefits is reduced from what we normally would pay as the primary plan. In most instances, the amounts we save as the secondary plan are put in a special reserve fund called a "COB benefits bank" or "COB savings account." A separate benefits bank accumulates for each Plan member and cannot be transferred to other family members. Your benefits bank accumulates on a calendar year basis and is reduced to zero at the end of the year. A new benefit bank is established as soon as there are new savings on a claim in the following year.

COB benefit bank accumulations are used to pay for allowable expenses that the In-Network Plan, as secondary plan, may not normally cover, or to pay for allowable expenses that are covered only in part by the In-Network Plan and the other plan. However, the reserve is not used to pay an amount the primary plan did not pay because the member failed to meet the primary plan’s guidelines. In addition, the reserve is not used for benefits that exceed Plan limitations such as mental health and chemical dependency benefit limits.

The Plan’s right to receive and release necessary information

The Plan may, with your written consent, release to, or obtain from any other insurer, organization or person, any necessary information we need to administer the coordination of your benefits. To claim benefits from the Providence Health Plan, you will need to give us the necessary information for this purpose.

For more information

Coordination of benefits rules governing payment of claims is complicated and specific. If you need more information about coordinating benefits between two or more health plans, please contact your Customer Service Team.

When your group coverage ends

The In-Network Plan membership and coverage will terminate for subscribers and their dependents if:

• The subscriber gives written notice of cancellation through the employer group.
• The subscriber dies. Coverage for dependents ends on the last day of the month in which the subscriber dies.
• The subscriber is no longer eligible for coverage. The employer group agrees to notify the Plan immediately of loss of eligibility.
• The employer voluntarily discontinues coverage with the Plan or the employer fails to pay premiums and the Plan terminates coverage.
• The Plan may terminate membership and coverage upon written notice in the event of (but not limited to) the following:
• The member fails to pay copayments or coinsurance by or for a specific member.
• The member furnishes incomplete, false, or misleading information to the Plan.
• The member permits the use of the Plan’s member identification card by another person or uses another member’s identification card to obtain services.

• The member misuses his or her Plan benefits, including use of emergency services, causes damage to a provider’s or hospital’s property, or is physically or verbally abusive toward the providers who are providing services, a provider’s employee, or an employee of the Plan.

• If the member’s employer group, or if the member (under a Continuation or Portability coverage plan) fails to pay any premium due the Plan within 31 days of the due date.

Certificate of Creditable Coverage

When you leave the Providence Health Plan you and/or your dependents will receive a form called a Certificate of Creditable Coverage which provides proof of prior medical coverage. You may need to furnish this certificate to another insurance carrier to obtain medical coverage in the future.

We will provide you written certification of your creditable coverage when:

• You cease to be covered under the Plan.
• You become covered under Continuation coverage.
• You cease to be covered under Continuation coverage.
• You request a Certificate of Creditable Coverage within 24 months of your termination of coverage.

This provision contains important information about your rights to Continuation Coverage, which is a temporary extension of coverage under the Plan available to you when you lose coverage by reason of certain stipulated events (Qualifying Event).  Because your Plan is sponsored by a church organization, it is not required by law to offer Continuation Coverage.  However, PeaceHealth voluntarily provides a form of Continuation Coverage which for the most part is consistent with federal law.  However, PeaceHealth is not undertaking to provide Continuation Coverage which is identical in all respects with federal law. 

In general, if a “qualified beneficiary” (generally you, your spouse or dependent) covered under the Plan experiences a “qualifying event” (generally a loss of coverage due to a specified event), the qualified beneficiary may elect to continue health coverage under the Plan for a period of time. 

Coverage must be elected on the election form provided by PeaceHealth.  You, your spouse and dependents should take time to carefully read the Continuation Coverage provisions. 

If you have questions, contact PeaceHealth Human Resources.

Continuation Coverage

Continuation Coverage is continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.”  Specific qualifying events are listed later in this notice.  Continuation Coverage is offered to each person who is a “qualified beneficiary.”  A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event.  Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries.  Under the Plan, qualified beneficiaries who elect Continuation Coverage must pay for Continuation Coverage. 

In order to be a qualified beneficiary, you, your spouse or dependent must be covered under the Plan on the day before the event that causes a loss of coverage.  In addition, if a child is born to you or placed for adoption with you during a period of Continuation Coverage, you may cover that child if you give proper notification within the time required. 

If at the time you would otherwise become eligible for Continuation Coverage, you and/or your covered dependents (spouse, children, etc.) are covered by another health plan or by Medicare and you and/or your covered dependents are not subject to any exclusion or limitation for a preexisting condition, then you and/or they will not be eligible to elect Continuation Coverage under this Plan.  So, by way of example, if at the time you terminate employment you are covered as a dependent under your spouse’s group health plan, you are not eligible for Continuation Coverage. 

If you are an employee, you will become a qualified beneficiary if you lose coverage under the Plan because either of the following qualifying events happens: 

1. Your hours of employment are reduced, or 
2. Your employment ends for any reason other than gross misconduct. 

If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens: 

1. Your spouse dies; 
2. Your spouse’s hours of employment are reduced; 
3. Your spouse’s employment ends for any reason other than his or her gross misconduct; 
4. Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or 
5. You become divorced or legally separated from your spouse. 

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens: 

1. The parent (employee) dies; 
2. The parent’s (employee’s) hours of employment are reduced;
3. The parent’s (employee’s) employment ends for any reason other than his or her gross misconduct;
4. The parent (employee) becomes enrolled in Medicare (Part A, Part B, or both);
5. The parent (employee) becomes divorced or legally separated from their spouse; or
6. The child ceases to be eligible for coverage under the Plan as a “dependent child.”

Notices and Election

If you lose coverage under the Plan as a result of one of the events listed above, then you may be entitled to elect Continuation Coverage.  You must give notice to PeaceHealth Human Resources of the occurrence of the event which causes the loss of coverage within 30 days. 

If you or a family member fail to notify PeaceHealth during the 30 day notice period, any family member who loses coverage will NOT be offered the option to elect Continuation Coverage.  Further, if you or a family member fail to notify PeaceHealth and, contrary to Plan terms, any claims are paid for expenses incurred after the last day of the month of the divorce, legal separation, or a child losing dependent status, then you and your family members will be required to reimburse the Plan for any claims so paid. 

Once PeaceHealth receives notice that a qualifying event has occurred, Continuation Coverage will be offered to each of the qualified beneficiaries.  For each qualified beneficiary who elects Continuation Coverage, Continuation Coverage will begin on the date that Plan coverage would otherwise have been lost. 

You (the employee) or your family member must elect Continuation Coverage within 60 days after Plan coverage ends, or if later, 60 days after PeaceHealth sends you or your family member notice of the right to elect Continuation Coverage.  If you or your family member do not elect Continuation Coverage within this 60-day election period, you will lose your right to elect Continuation Coverage. 

A covered employee or covered spouse of the covered employee may elect Continuation Coverage for all family members who were covered under the Plan on the day before the qualifying event.   The covered employee, and his or her covered spouse and covered dependent children, however, each have an independent right to elect Continuation Coverage.  Thus a covered spouse or dependent child may elect Continuation Coverage even if the covered employee does not elect it. 

Type of Coverage & Premium Payments

If Continuation Coverage is elected, your coverage will be identical to the coverage provided under the Plan to similarly situated employees or family members.  If the coverage for similarly situated employees or family members is modified, Continuation Coverage will be modified the same way. 

You (the employee) or a family member must pay the premium payments for the “initial premium months” by the 45th day after electing Continuation Coverage.  The initial premium months are the months that end on or before the 45th day after the date of the Continuation Coverage election.  All other premiums are due on the 1st of the month for which the premium is paid, subject to a 30-day grace period.  If the premium payments are not received within the 30-day grace period, your eligibility to continue Continuation Coverage will terminate. 

Maximum Coverage Periods

1.     18 Months.  If you (employee, spouse or dependent child) lose group health coverage because of the employee’s termination of employment (for reasons other than gross misconduct), reduction in hours, retirement or leave of absence, the maximum Continuation Coverage period (for the employee, spouse and dependent child) is 18 months from the date of termination or reduction in hours.  There are three exceptions:  

•     If an employee or family member is disabled at any time during the first 60 days of Continuation Coverage (running from the date of termination of employment or reduction in hours), the continuation of coverage period for all qualified beneficiaries under the qualifying event is 29 months from the date of termination or reduction in hours.  The Social Security Administration must formally determine under Title II (Old Age, Survivors, and Disability Insurance) or Title XVI (Supplemental Security Income) of the Social Security Act that the disability exists and when it began.  For the 29-month Continuation Coverage period to apply, notice of determination of disability under the Social Security Act must be provided by the disabled individual to PeaceHealth within the 18-month coverage period and within 60 days after the date of the disability determination. 

•       If a second qualifying event occurs (for example, the employee dies or becomes divorced) within the 18-month or 29-month coverage period, the maximum coverage period becomes 36 months from the date of the initial termination or reduction in hours.

•      If the qualifying event occurs within 18 months after the employee becomes entitled to Medicare, the maximum coverage period (for the spouse and dependent child) ends 36 months from the date the employee became entitled to Medicare.

2.     36 Months.  If you (spouse or dependent child) lose group health coverage because of the employee’s death, divorce, legal separation, or the employee’s becoming entitled to Medicare, or because you lose your status as a dependent under the Plan, the maximum coverage period (for spouse and dependent child) is 36 months from the date of the qualifying event. 

Special Circumstances

Newborn Children of, or Children Placed for Adoption with, the Covered Employee after the Qualifying Event 

If, during the period of Continuation Coverage, a child is born to the covered employee or is placed for adoption with the covered employee, the child is considered a qualified beneficiary.  The covered employee or other guardian may elect Continuation Coverage for the child, provided the child satisfies the otherwise applicable plan eligibility requirements (for example, age).  The covered employee or a family member must notify PeaceHealth within 60 days of the birth or placement to enroll the child on Continuation Coverage.  (The 60-day period is the Plan’s normal enrollment window for newborn or adopted children.)  If the covered employee or family member fails to so notify PeaceHealth in a timely fashion, the covered employee will NOT be offered the option to elect Continuation Coverage for the newborn or adopted child. 

Termination Before the End of Maximum Coverage Period

Continuation Coverage of the employee, spouse or dependent child will automatically terminate (even before the end of the maximum coverage period) when any one of the following five events occurs: 

1.  PeaceHealth no longer provides group health coverage to any of its employees; 

2.  The premium for Continuation Coverage is not timely paid; 

3.  You (employee, spouse or dependent child) become covered under another group health plan (as an employee or otherwise) that has no exclusion or limitation with respect to any preexisting condition that you have.  If the other plan has applicable exclusions or limitations, your Continuation Coverage will terminate after that exclusion or limitation no longer applies (for example, after a 12-month preexisting condition waiting period expires).  If you have elected Continuation Coverage, you have a duty to notify PeaceHealth within 30 days after the date you or your covered spouse or dependent becomes covered under another group health plan. 

4.     You (employee, spouse or dependent child) became entitled to Medicare benefits (applies only to the person who becomes entitled to Medicare); 

5.  If you (employee, spouse or dependent child) became entitled to a 29-month maximum coverage period due to disability of a qualified beneficiary, but then there is a final determination under Title II or XVI of the Social Security Act that the qualified beneficiary is no longer disabled (however, Continuation Coverage will not end until the month that begins more than 30 days after the determination). 

Other Information

If You Have Questions 

If you (the employee) or a family member have questions about your Continuation Coverage, you should contact your regional Human Resources department.  

Keep Your Plan Informed of Address Changes 

In order to protect your family’s rights, you should keep PeaceHealth informed of any changes in the addresses of family members.  You should keep a copy of this notice and any notices you send to PeaceHealth for your records. 

General Procedures 

Portability Coverage

If you lose eligibility for group coverage or Continuation continuation coverage by the Plan, you may be eligible for Portability coverage through the Oregon Medical Insurance Pool (OMIP). OMIP is not sponsored or endorsed by Providence Health Plan or PeaceHealth. Rather, OMIP is authorized under Oregon law to provide Portability coverage to certain Oregon residents who have lost coverage under a group health benefit plan.  Upon proper application and the payment of the applicable premiums, Portability coverage with OMIP will generally become effective as of the day following your termination of coverage under this Plan.

To be eligible for Portability coverage with OMIP, you must meet the following requirements:

1. You must have been covered under one or more Oregon group health benefit plans for at least 180 days and applied for Portability coverage no later than the 63^rd day after termination of your group coverage; and
2. You must be an Oregon resident at the time of application.

You are NOT eligible for a Portability Plan if:

1. You are eligible for federal Medicare coverage;
2. You remain eligible for your prior active group coverage;
3. You are covered under another group or individual plan, policy, contract, or agreement providing benefits for hospital or medical care; or
4. You move out of the State of Oregon

For further information regarding Portability coverage with OMIP, and to receive an application for coverage, call the OMIP administrator, Regence Blue Cross and Blue Shield, at 1-800-848-7280.

As a member of our health plan, you should know what to expect from us, as well as what we ask from you. Nobody knows more about your health than you and your doctor. We take responsibility for providing the very best health care services and benefits possible; your responsibility is to know how to use them well. Please take time to read and understand your benefits. We want you to have a positive experience with the In-Network Plan, and we’re ready to help in any way.

• Be cared for by people who respect your privacy and dignity.
• Be informed about the Plan, our providers, and the benefits and services you have available to you as a member.
• Receive information that helps you select a participating physician or provider whom you trust and with whom you feel comfortable.
• A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
• Receive information and clinical guidelines from your health care provider or your health plan that will enable you to make thoughtful decisions about your health care.
• Actively participate in decisions that relate to your health and your medical care through discussions with your health care provider or through written advance directives.
• Have access to medical services that are appropriate for your needs.
• Express a concern and receive a timely response from the Plan.
• Have your claims paid accurately and promptly.
• Request a review of any service not approved, and to receive prompt information regarding the outcome.
• Make recommendations regarding the member rights and responsibilities policy.
• Refuse care from specific providers.

• Read and understand the information you receive about the Plan, and call Customer Service if you have questions.
• Talk openly with your physician or provider and work toward a relationship built on mutual trust and cooperation.
• Follow the treatment plan that you and your practitioner have agreed upon.
• Provide to the extent possible medical information your physicians or providers request from you.
• Do your part to prevent disease and injury. Try to make positive, healthful choices. If you do become ill or injured, seek appropriate medical care promptly.
• Treat your physicians or providers courteously.
• Make your required copayment at the time of service.
• Show your member identification card whenever you receive medical services.
• Let us know if you have concerns, or if you feel that any of your rights are being compromised, so that we can act on your behalf.
• Call or write within 180 days of service if you wish to request a review of services provided or appeal a Plan decision.
• Notify Customer Service if your address changes.

• Respect and honor your rights.
• Ensure timely access to appropriate health care services.
• Enable you to see physicians or providers who meet your needs.
• Develop a variety of benefits to serve you well.
• Assure the ongoing quality of our providers and services.
• Contract with providers who are capable, competent, and committed to excellence.
• Make it easy and convenient for you to appeal any policy or decision that you believe prevents you from receiving appropriate care.
• Provide you with accurate up-to-date information about the Plan and participating providers.
• Provide you with information and services designed to help you maintain good health and receive the greatest benefit from the services we offer.
• Ensure privacy and confidentiality of your medical records with access according to law.
• Ensure that your interests are well represented in decisions about Plan policy and governance.
• Encourage physicians and providers to make medical decisions that are always in your best interest.

Providence Health Plan members are entitled to comprehensive medical care within the standards of good medical practice. The Providence Health Plan’s medical directors and special committees of participating providers determine which services are medically necessary using these guidelines:

• All medical services that are appropriate and necessary for the diagnosis and treatment of symptoms, illness, disease, injury or condition that is harmful or threatening to your life or health.
• Services that are within the standard of good medical practice within the organized medical community.
  Example: Your provider suggests a treatment using a machine that has not been approved for use in the United States. The Plan probably would not pay for that treatment.
• Services at the most appropriate level that can safely be provided.
  Example: You go to a hospital emergency room to have stitches removed, rather than wait for an appointment in your doctor’s office. The Plan would not pay for that visit.
• Services that are not primarily for your convenience, or the convenience of your provider, hospital or any other health care provider:
  Example: You stay an extra day in the hospital only because the relative who will help you during recovery can’t pick you up until the next morning. The Plan may not pay for the extra day.

Be careful… just because a treatment was prescribed or performed by a qualified health care provider does not necessarily mean that it is medically necessary under our guidelines.

The Plan has the legal right to determine which medical conditions are covered by this plan, and to what extent the conditions are covered.

Medical cost management

The Plan reserves the right to deny payment for services that are judged not to meet the criteria maintained by Providence Health Plan to determine medical necessity. A decision by the Plan following this review may be appealed as described under "Problem Resolution," section. When there is more than one alternative available, the least costly among medically appropriate alternatives will be approved.

In addition, the Plan reserves the right to make substitutions for the covered services listed in this Member Handbook and your Plan Document. Substituted services must be:

• Medically necessary.
• Have your knowledge and agreement while receiving the service.
• Be prescribed and approved by an approved category of provider.
• Offer a medical therapeutic value at least equal to the covered service that would otherwise be performed or given.

Concurrent care decisions 

If the Plan has approved an ongoing course of treatment for you and we then determine through our medical cost management procedures to reduce or terminate that course of treatment, we will provide advance notice to you of that decision. You may request a reconsideration of our decision by submitting an oral or written request at least 24 hours before the course of treatment is scheduled to end. We will then notify you of our reconsideration decision within 24 hours after we receive your request. 

See “Problem Resolution:Appeals involving prior authorization denials,” regarding specific appeal procedures for prior authorization requests that are denied by PHP. 

Informal Member Problem Resolution

Every Providence Health Plan employee shares responsibility for ensuring member satisfaction. If you have a problem or concern about your coverage, or services you have received, let us know what the problem or concern is and how you would like it to be addressed.

Your Customer Service Team is available to provide information and assistance. You may call us or set up an appointment with us to discuss your concern. If you have special needs, such as a hearing impairment, call our TTY (telephone device for the hearing impaired) number. Please contact us so we may help you with whatever special needs you may have.

At any time during the grievance and appeal process you may seek assistance from the Oregon Insurance Division with your concerns regarding our decisions and benefits. You may contact the Oregon Insurance Division at:

Oregon Insurance Division

Consumer Protection Unit

350 Winter St. NE, Room 440-2

Salem, OR 97301-3883

1-503-947-7984 or 1-888-877-4894

www.cbs.state.or.us/external/ins/

If you disagree with the Providence Health Plan’s decision about your medical bills or health care services you have the right to appeal. You may appeal if the Plan has not paid a bill, not paid the bill in full, will not approve care that you feel should be covered or is stopping care you believe you still need. You also may file a quality of care or general complaint with the Providence Health Plan. Please include as much information as possible including the date of the incident, name of individuals involved, and the specific circumstances. To the extent possible, complaints filed by telephone will be resolved at the point of service by your Customer Service Team. All levels of Grievances and Appeals will be acknowledged within seven days of receipt by the Plan and resolved within 30 calendar days or sooner depending on the clinical urgency. With regard to the initial grievance, an additional 15 days may be requested to resolve the issue if, before the 30^th day, we provide you with notice of the delay. 

In filing a grievance or appeal: 

• You can submit written comments, documents, records and other information relating to your grievance or appeal and the Plan will consider that information in the review process; 

• You can, upon request and free of charge, have reasonable access to and copies of the documents and records held by the Plan that relate to your grievance or appeal.

Initial grievance

If you disagree with our decision you have the right to file an initial grievance. You must file your initial grievance within 180 days of the date on the initial decision notice to deny payment or coverage or requested services. Please advise us of any additional information that you want considered in the review process. If you are seeing a provider that does not participate with the Providence Health Plan, you should contact the provider’s office and sign a release of records form for the necessary records to be forwarded to the Providence Health Plan for the review process.

First level of appeal

If you disagree with our decision on your initial grievance, you have the right to file a first level of appeal. Your appeal and any additional information you may want reviewed should be forwarded within 60 days from the date on the initial grievance denial notice. Plan staff not involved in the initial grievance will review the first level of appeal.

Second level of appeal

If you are not satisfied with the first level of appeal decision, you may request that the Plan’s Grievance Committee review your appeal. The Grievance Committee is made up of medical professionals, Plan staff, and a community representative. You must request the Grievance Committee review within 60 days of the date on the first level of appeal decision notice. You may present your case to the Grievance Committee in writing, in person, or by telephone conference call. The Grievance Committee will review the documentation presented by you and send a written explanation of its decision.

If you appeal a prior authorization request that has been denied by the Plan for a non-urgent medical condition, we will notify you of our initial grievance decision or first level appeal decision within 15 days after we receive your appeal. If your appeal involves an urgent medical condition, we will notify you of our initial grievance decision within 72 hours after we receive your appeal.

If you are not satisfied with the decision from the Grievance Committee and your appeal involves a denial of services because they are not medically necessary, not an active course of treatment for purposes of continuity of care, or because they are experimental/investigational, you may request an external review by an Independent Review Organization (IRO). Your request must be made within 180 days after you receive the Plan’s final internal review decision from the Grievance Committee. 

 

If you agree, we may waive the requirement that you exhaust the internal review process before beginning the external review process. When the external review process is begun, an IRO will be assigned to the case by the director’s office and we will forward complete documentation regarding the case to the IRO. The IRO is entirely independent of Providence Health Plan and performs its review under a contract with the director’s office.  
Providence Health Plan agrees to be bound by the decisions of an IRO regarding medically necessary treatment, notwithstanding the definition of medical necessity in the Plan, experimental/investigational treatment and an active course of treatment for purposes of continuity of care in cases involving Plan members and to comply with those decisions. All costs for the handling of external review cases are paid by Providence Health Plan and these provisions are administered in accordance with the regulatory requirements established by law and regulation in the state of Oregon.

If you are dissatisfied with the Plan’s decision denying a proposed course of treatment or service on the basis that it is experimental or investigational, you may submit a written request to appeal this decision. We will acknowledge receipt of your notice of appeal within seven calendar days. An appropriate medical consultant or peer review committee shall review your appeal and notify you of their decision within 30 days of the first notice.

Contact your Customer Service Team at 503-574-7500 or 1-800-878-4445.

 If you are hearing impaired and use a Teletype (TTY) Device, please call our TTY line at 503-574-8702 or 1- 888-244-6642. Written Grievances or Appeals should be sent to:

Providence Health Plan, Attn: Appeals and Grievance Dept.

P.O. Box 4327

Portland, OR 97208-4327

You may fax your grievance or appeal to 503-574-8757 or 1-800-396-4778, or you may hand deliver it to the following address (if mailing use only the post office box address listed above):

Providence Health Plan, Attn: Appeals and Grievance Dept.

3601 SW Murray Blvd., Suite 10

Beaverton, OR 97208-2359

Additional information

If you would like to receive our annual report on grievances and appeals, please contact your Customer Service Team.

New application of existing technology coverage determination

New technologies and new applications of existing technologies are evaluated and approved for coverage when they provide a demonstrable benefit for a particular illness or disease; are scientifically proven to be safe and efficacious; and there is no equally effective or less costly alternative.

Emerging and innovative technologies are monitored by the Plan through review of trend reports from technology assessment bodies; government publications; medical journals; and information provided by providers and professional societies.

A systematic process for evaluating a new technology or new application of an existing technology is proactively initiated when sufficient scientific information is available.

Plan-developed standards guide the evaluation process to ensure appropriate coverage determinations. New technology must minimally meet the following guidelines to be approved for coverage.

• Technology must improve health outcomes. The beneficial effects must outweigh any harmful effects on health outcomes. It must improve the length of life, ability to function or quality of life.
• Technology must be as beneficial as any established alternative. It should improve the net health outcome as much, or more than established alternatives.
• Application of technology must be appropriate, in keeping with good medical standards, and useful outside of investigational settings.
• Technology must meet government approval to market by appropriate regulatory agency as applicable.
• Criteria must be supported with information provided by well-conducted investigations published in peer-reviewed journals. The scientific evidence must document conclusions which are based on established medical facts.
• Opinions and evaluations of professional organizations, panels or technology assessment bodies are evaluated based on the scientific quality of the supporting evidence.

Technology evaluation process

A core committee of Plan Medical Directors and high level physician specialists, practitioners and/or pharmacists evaluate and recommend coverage for new technologies. Their decisions are based on information provided by professional assessment and policy development organizations, as well as other medical experts.

Expedited review

Requests for coverage of new technology may occur before formal policy has been developed. In these cases, an expedited review is implemented and a decision is made on a case-by-case basis. This is separate and distinct from the Problem Resolution procedure.

Disclosure of Plan information

You may obtain a current financial statement of Providence Health Plan by writing or calling our office at:

Providence Health Plan

P.O. Box 4327

Portland, OR 97208-4327

503-574-7500 or toll free 1-800-878-4445

Submitting a claim

All Participating Plan and many non-participating providers will bill Providence Health Plan for you. You may receive a bill for information purposes only, stating “Your insurance has been billed.

In order to ensure the timely processing of claims, you are encouraged to submit a claim for treatment within 60 days of the date of service. The Plan will not pay claims received more than 12 months after the date of service. However, exceptions will be made if we receive documentation of your legal incapacitation. The Plan will pay a covered expense to the provider, the member, or jointly to both. If the Plan mistakenly makes a payment to which a member is not entitled, the Plan may recover the payment.  You may submit claims to: 

 

Providence Health Plan

ATT: Claims Dept.

P.O. Box 3125

Portland, OR 97208-3125

If the Plan mistakenly makes a payment to which a member is not entitled, the Plan may recover the payment.

Shared payments for members

Specific copayment /coinsurance amounts are listed on your plan’s Summary of Benefits.

Additional information available upon request

The following information about Providence Health Plan is available from the Oregon Insurance Division:

• Annual summary of grievances and appeals.
• Annual summary of utilization review policies.
• Annual summary of quality assessment activities.
• Annual summary of network monitoring to ensure that all covered services are reasonably accessible to members.
• A summary of the results of all federal reports and accreditation surveys available to the public.
• A summary of health promotion and disease prevention activities.

This information is available by calling 1-503-947-7984 or by writing to the Oregon Insurance Division, Consumer Protection Unit, 350 Winter Street NE, Room 440-2, Salem, OR 97301-3883. You also can contact them through the Internet at: www.cbs.state.or.us/ins/

Advance directives

Designating others to make your health care decisions

In some cases an illness or injury may prevent you from expressing your wishes about the medical care you would like to receive. As a result, state and federal law allows adults to make certain health care decisions in advance while they are competent and able to do so. Individuals also may name others to make decisions for them if they later become unable to do so. These advance decisions are called "advanced directives" when the patient’s wishes are made in writing.

Providence Health Plan members receive advance directive booklets. The booklet includes the advance directive form. If you would like another booklet sent to you, please contact your Customer Service Team. You may also obtain the forms at any participating hospital.

You should give a copy of your advance directive to your physician or provider. In addition, whenever you are admitted to a hospital or skilled nursing facility, you will have the opportunity to revise your advance directive instructions by completing a new form available at the facility. You may also simply give the hospital or skilled nursing facility a copy of the advance directives you have prepared.

Notice of provider termination 

When a participating provider terminates from the Plan, we will notify those members who we know are under the care of the terminated provider within 10 days of either the termination date, or of our knowledge of the termination date. 

If you are in an active course of treatment with a participating provider whose contract of participation with the Plan terminates, you may be eligible to obtain covered services from that provider for a limited period of time after the contract of participation ends. The maximum period of continuity of care is 120 days or, in the case of pregnancy, 45 days after delivery. In no event will continuity of care apply after your Plan coverage terminates or once you change to another Plan with us that does not qualify for continuity of care. 

To receive continuity of care, you need to request it by calling your Customer Service Team. Once determined eligible, you will be sent a Continuity of Care form that must be completed and signed by both you and your provider. Your provider must agree that continuity of care is necessary and agree to adhere to the terms of the provider contract she/he had with Providence Health Plan. 

Continuity of care is not available when the provider: 

●   Has retired or died;  

●   No longer holds an active medical license; 

●   Relocates out of the service area;

●   Is on sabbatical;

●   Is prevented from continuing to care for patients because of other circumstances; or

●   Has been terminated for quality of care issues and has exhausted all contractual appeal rights.

If, for any reason, there is a change in your benefits, you will receive a benefit change letter from the Plan describing the applicable changes.

In certain cases, a member may no longer be eligible for the Plan or the Plan may make a decision to terminate membership. These situations would result in a termination of benefits. Please refer to "Termination of Coverage," section, for more detailed information.

When you accept these benefits, you also agree to have your medical records examined by the Plan under certain specific circumstances. Medical records may be examined for the purpose of utilization review, quality assurance, and peer review by the Plan or our designee. Medical information, such as claims data may be analyzed for quality improvement purposes. The Plan respects the privacy of our members. Please refer to the following page for the Plan’s confidentiality policy. 

Privacy of member information 

Medical care is a deeply personal issue for people. All of us need to know that     information about our health care is private and confidential. Providence Health Plan (PHP) respects the privacy of all enrollees and takes great care to determine when it is appropriate to share your personal health information. Such uses may include intervention programs that improve your medical treatment, quality measurement processes, an audit of your claims record to ensure accurate and timely payment and release of information to your primary or secondary insurance carrier to assist with coordination of benefits.

 

PHP makes every effort to release only the amount of information necessary to meet any release requirement and only releases information on a need to know basis. Also, wherever feasible, identifiable information is removed from any information shared within and outside of PHP. 

To secure the confidentiality of medical information, PHP has the following procedures in place: 

●   Access to a member’s medical information held by the plan is restricted to only those Providence employees who need this information and to the member. Entries into member records are tracked for security purposes. Employees must report any security violations. 

●   Unique and secured log-in names and passwords are required to access the PHP computer system. In addition, “firewalls,” encryption and data backup systems are used. Similar strategies are used for protecting confidential information on our Internet site. 

●   Providence employees are educated about privacy issues and sign a confidentiality statement upon employment, then review the information and sign again each year. 

●   Each department within PHP adopts specific policies to monitor the handling of member information. 

●    PHP uses member personal health information within PHP to process claims, for disease management or for quality improvement purposes. 

●   Members must sign an authorization to release identifiable member information outside of PHP or its authorized agents, except when the law requires or permits such a release or for treatment, billing and healthcare operations...

●   When member information is used in health studies, identifiable information is not released. All member-specific information has identifying information removed, and aggregated data are used as early in the measurement process as possible. The privacy of PHP members is completely protected. 

●   Our agreements with participating providers contain confidentiality provisions that require providers treat your personal health information with the same care as PHP. 

●   You have the right to register a complaint if you believe your privacy is compromised in any manner. 

●   Members may request to see their medical records. Call your physician’s or provider’s office to ask how to schedule a visit for this purpose. 

If you have questions about your own medical information or those of another member of your household, please call your Customer Service Team at 503-574-7500 or toll free, 1-800-878-4445.

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Member forums

Your input is valuable to us. Periodically, forums are held where members, providers, and employers/purchasers present their views and suggestions to the executive staff of Providence Health Plan. This input is used to assist the Plan in developing meaningful policies that benefit all members. Future meeting times and locations will be announced in the Providence Health Plan member newsletter.

Non-discrimination

Providence Health Plan will not refuse to enter into, cancel or decline to renew a contract because of any member’s race, color, national origin, religion, status as a victim of domestic violence, gender, sexual orientation, marital status, or age.

Quality management

If you would like to receive a summary of Providence Health Plan’s programs to monitor and improve the quality of health services in the community, please contact your Customer Service Team.

Provider payments

Providence Health Plan pays participating providers on a discounted fee-for-service arrangement. Hospitals are reimbursed based on the services they provide. The hospitals are motivated to provide the right amount of care in the proper setting for their patients. Hospitals work with personal physicians/providers and other providers to give members quality care and to keep health care costs within budget.

Additional information

If you would like to receive additional detailed information regarding the reimbursement arrangements Providence Health Plan holds with our participating providers, please call your Customer Service Team.

Utilization Management

Providence Health Plan (PHP) works with physicians and other health care providers to offer appropriate medical care and to improve the health of our members. Your health is our first priority.

We support providers to make sound medical decisions on behalf of their patients, our members. We do not offer incentives or reward any provider or PHP staff for denying claims or not providing care. We encourage providers to explain all medical options to members, whether those options are covered by the In-Network Plan or not. We want you and your provider to work together to make the best decisions for treatment.

We encourage providers to manage and improve care for our members, not to restrict care. Like most health plans, we do have some restrictions about which benefits are covered by the plan purchased by your employer, by you as an individual or by a government contract. We explain what benefits are covered in your Member Handbook so you can know about those in advance.

We do ask you whenever possible to work with participating health care providers who have agreed in advance to our schedule of fees, to our routines of care known as clinical practice guidelines, and who will refer you to other care providers with whom we work. The health care providers we ask you to work with are listed in our Online Participating Provider Directory for Personal Option Plan members and in a paper directory that you can receive from us by calling your Customer Service Team.

PHP does require advance notification – or prior authorization – from providers for some medical procedures. This allows the plan to commit to appropriate payment for these services and ensure their medical appropriateness. This may include review of the member’s medical records by appropriate PHP clinical staff so that we ensure appropriate application of benefits and payments. Also, we provide case management assistance for members with complex medical needs who may benefit from additional assistance to maximize and coordinate the care they receive from health care providers.

If you have a prescription drug benefit through your employer’s plan, you should know that PHP recommends the use of generic formulas. Some drugs will require prior authorization for benefit payment, or may be paid only equal to the generic drug equivalent. We frequently update the types of prescription drugs we cover. If you would like to know which drugs require prior authorization or to what benefit level a specific medication is covered, please contact your Providence Health Plan Customer Service Team.

Always present your current Providence Health Plan identification card and pay your copayment at the time of purchase.

If you want more information about how PHP makes decisions about covering medical treatment (also called "utilization management"), please call your Customer Service Team.

Amendment or termination of plan 

The employer sponsor of your group plan reserves the right at any time to amend or terminate in whole or part any of the provisions of the plan or any of the benefits provided under the plan. Any such amendment or termination may take effect retroactively or otherwise. In the event of a termination or reduction of benefits under the plan, the plan will be liable only for benefit payments due and owing as of the effective date of such termination or reduction and no payments scheduled to be made on or after such effective date will result in any liability to the plan or your employer. 

• Acute care is care received in an inpatient hospital setting.
• Annual out-of-pocket maximum is the limitation on the amount of money you will have to spend for specified covered health services in a calendar year. This maximum amount is shown on your Summary of Benefits.
• A calendar year marks the time beginning January 1 and ending December 31.
• A Certificate of Creditable Coverage provides proof of prior medical coverage. You may need to furnish this certificate to another insurance carrier to obtain medical coverage in the future.
• A certified nurse midwife is a person who is licensed or certified to supervise the conduct of labor and childbirth; advise the parent as to the progress of the childbirth; and furnish prenatal, intrapartum, and postpartum care.
• Coinsurance is the percentage of cost that you may need to pay for a covered service. Coinsurance amounts are listed on your Summary of Benefits.
• A condition is an impaired state of health, due to a specific illness or injury that requires skilled professional treatment or services.
• A copayment is the fixed dollar amount you pay for a covered service at the time the care is provided. Copayment amounts are listed on your Summary of Benefits.
• Cosmetic treatment is defined as medical or surgical treatment primarily for the purpose of improving appearance or self esteem.
• Custodial care services are services or supplies that do not require the technical skills of a licensed nurse at all times, assist solely in activities of daily living activities or personal grooming and are not likely to improve your condition.
• Dependent means a person for whom you or your legal spouse provided, during the most recent calendar year, more than 50% of the person's support. In the case of a student, amounts received as scholarships for study will not be considered in determining source of support. If no one provided more than 50% of the person’s support, the person will be treated as the dependent of whoever provided the most support. A child will also be considered a dependent if you or your spouse are required to provide medical care to a child under a qualified medical child support order, as defined by federal law.
• Developmental delay is defined as a delay in the ability to learn, reason or communicate.
• Durable medical equipment (DME) is equipment which is primarily and customarily used to serve a medical purpose, and generally is not useful to a person in the absence of illness or injury. It can withstand repeated use and is generally considered to be safe and effective for the purpose intended. DME may include items such as oxygen, wheelchairs, and other medically necessary equipment required for the treatment of an illness or injury.
• An emergency medical condition is a medical condition that manifests itself by symptoms of sufficient severity that a prudent lay person, possessing an average knowledge of health and medicine, would reasonably expect that failure to receive immediate medical attention would place the health of a person (or a fetus in the case of a pregnant woman) in serious jeopardy.
• Experimental, investigational or for research purposes, means any services determined by Providence Health Plan or our authorizing agent to not be medically necessary or accepted medical practice in the service area. In determining whether services are experimental, investigational, or for research purposes, the Plan will consider whether services are, in general: used in the medical community in the state of Oregon; under continued scientific testing and research; show a demonstrable benefit for a particular illness or disease; proven to be safe and efficacious; and approved for use by appropriate government agencies. The Plan includes a determination on a case by case basis of whether the requested service will result in greater benefits than other generally available services, and will not approve such a request if the service poses a significant risk to the health or safety of the patient. The Plan retains documentation of the criteria used to define a service deemed to be experimental, investigational or for research purposes and will make this available for review upon request.
• A family practice physician is a licensed personal physician/provider trained to diagnose and provide health care to patients of all ages. These providers are trained to provide routine gynecological care (including the annual gynecological exam) and some also provide obstetric care.
• A general practice physician is a licensed personal physician/provider trained to diagnose and provide health care services, including routine gynecological care and the annual gynecological exam, to patients of all ages.
• A gynecologist is a licensed physician specializing in the diagnosis and treatment of the diseases of women’s reproductive systems. Some gynecologists have been approved to act as personal physicians/providers and will be listed as such in the Online Participating Provider Directory.
• A member identification card is issued to each member enrolled in the Providence Health Plan. The card identifies you as a Plan member and includes important information about your coverage. Always present your card when you seek medical care or benefits.
• Infertility is defined as the inability to become pregnant after a year of unprotected intercourse. Or, the inability to carry pregnancy to term as evidenced by three (3) consecutive spontaneous abortions (miscarriages).
• An internist is a licensed personal physician/provider who is trained to diagnose and provide health care services to adults and teens, including routine gynecological care and the annual gynecological exam for women.
• Medically necessary refers to treatment which, as determined by the Plan, is required to treat or care for symptoms of an illness or injury or to diagnose an illness or condition that is harmful to life or health. Medically necessary services or supplies must be: appropriate as to place or level of care in amount, duration, and frequency for the treatment of the condition; not be provided primarily for convenience; appropriate and in keeping with widely-accepted standards of practice in the community; and likely to stabilize or improve a member’s medical condition. The fact that services are provided, prescribed or approved by a physician or provider does not in and of itself mean that the services are medically necessary.
• Members are the eligible individuals covered by the In-Network Plan.
• A nurse practitioner is a licensed nurse who has a Master’s Degree in nursing and advanced training which allows him or her to provide primary care. Some nurse practitioners have been approved to act as personal physicians/providers and will be listed in our Online Participating Provider Directory.
• An obstetrician is a provider specializing in the medical care related to pregnancy and the birth of children. Some obstetricians have been approved to act as personal physicians/providers and will be listed in our Online Participating Provider Directory.

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• An Out-of-Area Dependent is an eligible family dependent of a subscriber, who does not reside in the Plan’s service area and who is properly enrolled in the Plan as an Out-of-Area Dependent. A dependent child who is an eligible family dependent and who resides out of the service area for the purpose of attending school is eligible to be enrolled as an Out-of-Area Dependent. The subscriber’s spouse also is eligible to be enrolled as an Out-of-Area Dependent.
• An Out-of-Area Subscriber is an subscriber, who does not reside in the Plan’s service area and who is properly enrolled in the In-Network  plan as an Out-of-Area Subscriber. An Out-of-Area Subscriber's dependents also are eligible to receive the same benefits as the Out-of-Area Subscriber.  Only certain PeaceHealth employees are eligible to become Out-of-Area Subscribers.
• A pediatrician is a personal physician/provider trained to diagnose and provide health care services to infants, children, and adolescents.
• A physician assistant provides medical services under the direction and supervision of a licensed physician. Some physician assistants have been approved to act as personal physicians/providers and will be listed in our Online Participating Provider Directory
• Plan means the In-Network Plan.
• A participating provider or Plan provider is any credentialed physician, provider, hospital, or facility which has an Agreement with Providence Health Plan to provide care to Plan members.
• Prior authorized services are services which require you and/or your provider to seek Plan confirmation before seeking or receiving care. A prior authorization review will determine if the proposed service is medically necessary, eligible as a covered service and if an individual is a member at the time of the proposed service.
• A personal physician or provider is a participating provider specializing in family practice, general practice, internal medicine or pediatrics; a nurse practitioner; a certified nurse midwife; or a physician assistant, when providing services under the supervision of a physician; who agrees to be responsible for the member’s continuing medical care by serving as case manager. Adult female members also may select a provider specializing in obstetrics or gynecology; a nurse practitioner; a certified nurse midwife; or a physician assistant specializing in women’s health care as their personal physician/provider. (Note: Not all these providers are personal physicians/providers — see the Online Participating Provider Directory for a listing of designated personal physicians/providers.)
• A qualified practitioner means a physician, women's health care provider, nurse practitioner, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally licensed by the appropriate state agency to diagnose or treat a bodily injury or illness and who provides covered services within the scope of that license.
• The Providence Health Plan service area is a defined geographical area. See our service area map.
• A skilled nursing facility (SNF) is a convalescent or chronic disease facility which is accredited by the Joint Commission on Accreditation of Hospitals or certified as an "SNF" by the Secretary of Health & Human Services according to Title XVIII of the Social Security Act as amended, section (j).
• A specialist is a nurse, physician or other health care professional who has advanced education and training in one clinical area of practice.
• A subscriber is the employee of the Group whose employment or membership in the Group establishes eligibility for his or her dependents under the Providence Health Plan policy.
• The Summary of Benefits is a description of your plan’s benefits and copayments/coinsurance.
• Usual, customary, and reasonable charges (UCR) are charges that the Plan determines fall within a range of those most frequently charged for services and supplies. The amount determined is based on charges in the community where the services and supplies were furnished, by those who provide them.
• A women’s health care provider is an obstetrician, gynecologist, physician assistant specializing in women’s health, advanced registered nurse practitioner specializing in women’s health, or a certified nurse midwife practicing within the applicable lawful scope of practice. Naturopaths or any other alternative care providers are NOT considered women’s health care providers.

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Service Area Map

Click on Map to Enlarge