* Deductible does not apply

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 your PeaceHealth's 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.

• Alternative care, including acupuncture, chiropractic and naturopathic care

• 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 PeaceHealth's 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 PeaceHealth's 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, 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 an Providence Health Plan member, present your member identification card and pay your copayment 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 an enrolled Out-of-Area Dependent, 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 Providence Health 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.

This section summarizes basic  information you need to know to take advantage of the benefits offered by your Open Network Plus Plan.

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 Providence Health Plan to arrange for any Plan prior authorization requirements that may be required for certain covered services.  For more information on prior authorization see In-Plan covered services.

Open Network Plus Plan members also have an additional Out-of-Network benefit that gives them access to non-participating providers. For more information, see "Using Your Open Network Plus Plan, Out-of-Network Benefit," section.

Open Network Plus Plan enrolled Out-of-Area Dependents have a special Out-of-Area benefit allowing them to use non-participating providers. For further information, see "Enrolled Out-of-Area Dependent 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 Providence Health Plan visit our Online Participating Provider Directory for Personal Option and Open Option Plan members 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 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 a 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.

• 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. Copayment 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 Open Network Plus Plan has both a per person and per family annual (calendar year) out-of-pocket maximum. The Open Network Plus Plan has two different sets of per person/per family maximums: one for payments you make for covered services when you use the In-Network benefit and one for payments you make for covered services when you use the Out-of-Network benefit. In-Network and Out-of-Network maximums accumulate separately and are not combined. Your maximums are listed on your Open Network Plus Plan Summary of Benefits.  

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 Summary of Benefits, you will have no additional out-of-pocket costs for covered services for the remainder of the calendar year.

Your Open Network Plus Plan has a per person and per family out-of-network deductible. For out-of-network benefits only, the deductible must be met each plan year before the plan will begin paying for covered services.  Deductible amounts should be paid directly to your providers. A per person deductible needs to be met by each individual family member. If three individual family members meet this deductible, then the family deductible will apply. No further per person deductibles will need to be met by any other family members. Payments toward meeting your deductible do not apply to your out-of-pocket maximums.

Applicable charges used to meet any portion of the deductible during the fourth quarter of a calendar year will be applied toward the next year’s deductible.

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 chiropractic care.

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

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."

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.

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 Open Network Plus 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 $600 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.

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.”

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.

This section summarizes basic information you need to know for taking advantage of the non-participating provider or Out-of-Network benefit offered by your Providence Open Network Plus Plan. For information on your In-Network benefits, see "Using Your Open Network Plus Plan In-Network Benefits," section.

Out-of-Network Benefits

As an Open Network Plus Plan member, you may choose to seek care through participating providers using your In-Network benefit or seek care through non-participating providers by using your Out-of-Network benefit. (Some services are covered only when you use your In-Network benefit, see your Summary of Benefits for details.) Generally, when you use your Out-of-Network benefits your member coinsurance payments will be higher than when you use In-Network benefits. It is usually to your advantage to use your In-Network benefits whenever you can. Your Out-of-Network benefits are described in the "Out-of-Network" column on your Summary of Benefits.

After you meet your Plan’s deductible, Out-of-Network benefits are paid according to usual, customary and reasonable (UCR) charges. Amounts charged by a non-participating provider in excess of UCR are your responsibility and do not apply to your out-of-pocket maximums or deductibles. For a more thorough explanation on UCR charges, see "How the Plan Pays for Non-participating Provider Covered Services (UCR)."

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.

The following services are not covered under your Out-of-Network benefit. These services are only covered under your In-Network benefit:

• Infertility/fertility services.
• Non-surgical temporomandibular joint (TMJ) services.

Prior authorization is required for certain services if you choose to receive them from a non-participating provider. For a list of these services and how to obtain prior authorization, see "Prior Authorization."

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.

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 Open Network Plus 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 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 copayment

You are responsible for your plan’s copayment/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 copayment/coinsurance at the time you receive care. You are responsible for your plan’s copayment/ coinsurance for each hospital emergency room visit. Please refer to your Summary of Benefits for your copayment/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 will cover urgent care services received from a non-participating urgent care facility while you are inside the service area at the In-Network benefit. If you receive urgent care services from a non-participating urgent care facility when you are outside the Plan’s service area, these services will be covered under the Out-of-Network benefit. See your plan’s Summary of Benefits for details.

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.

You must use participating providers to receive In-Network benefits for the covered services listed in this section. If you use non-participating providers, your Out-of-Network benefits will apply. See "Using Your Plan Out-of-Network Benefit," section, for details on using your Out-of-Network benefit.

(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 an 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 copayment/coinsurance may differ from your annual gynecological exam copayment/coinsurance. See your plan’s Summary of Benefits for details on your copayment/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 copayment. For example – You see your personal physician/provider for an office surgery. You would pay your office visit copayment 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 copayment/coinsurance. Your Summary of Benefits lists your copayment/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 Open Network Plus 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.

Open Network Plus Plan members using the Out-of-Network benefit and enrolled out-of-area dependents: You are responsible for making sure inpatient hospitalization services are prior authorized by the Plan before receiving this care from a non-participating hospital.

Only medically necessary hospital services are covered. Covered inpatient services received in a hospital are:

• Acute (inpatient) care, when medically necessary.
• A semi-private room (unless a private room is medically necessary).
• Coronary care and intensive care, when necessary.
• Isolation care, when necessary.
• Hospital services and supplies necessary for treatment and furnished by the hospital, such as operating and recovery rooms, anesthesia, dressings, medications, oxygen, x-ray, and laboratory services during the period of inpatient hospitalization. (Personal items such as guest meals, slippers, etc., are not covered.)

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.

Open Network Plus Plan members using the Out-of-Network benefit and enrolled out-of-area dependents: You are responsible for making sure inpatient rehabilitative 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.

Open Network Plus Plan members using the Out-of-Network benefit and enrolled out-of-area dependents: You are responsible for making sure skilled nursing facility services are prior authorized by the Plan before receiving this care from a non-participating facility

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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 Open Network Plus Plan coverage by contacting your employer and/or your Customer Service Team. Your baby is covered by the Open Network Plus 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 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.

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 a