Page 45 - Aegion PPO SPDs
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HOW YOUR PLAN WORKS
Introduction
Your health Plan is a Preferred Provider Organization (PPO) for all Members except residents of
Missouri; Members residing in Missouri are part of a Point of Service (POS) Plan. The Plan is divided
into two sets of benefits: Network and Out-of-Network. If You choose a Network Provider, You will receive
Network benefits. Members who are residents of Missouri must use the appropriate POS Network
Provider in their respective states to receive Network benefits. Utilizing this method means You will
not have to pay as much money; Your Out-of-Pocket expenses will be higher when You use Out-of-Network
Providers.
Providers are compensated using a variety of payment arrangements, including fee for service, per diem,
discounted fees, and global reimbursement.
All Covered Services must be Medically Necessary, and coverage or certification of services that are not
Medically Necessary may be denied.
Network Services
When You use a Network Provider or get care as part of an Authorized Service, Covered Services will be
covered at the Network level. Regardless of Medical Necessity, benefits will be denied for care that is not
a Covered Service. The Plan has the final authority to decide the Medical Necessity of the service.
Network Providers include Primary Care Physicians / Providers (PCPs), Specialists (Specialty Care
Physicians / Providers - SCPs), other professional Providers, Hospitals, and other Facilities who contract
with us to care for You. Referrals are never needed to visit a Network Specialist, including behavioral health
Providers.
To see a Doctor, call their office:
Tell them You are an Anthem Member,
Have Your Member Identification Card handy. The Doctor’s office may ask You for Your group or
Member ID number.
Tell them the reason for Your visit.
When You go to the office, be sure to bring Your Member Identification Card with You.
For services from Network Providers:
1. You will not need to file claims. Network Providers will file claims for Covered Services for You. (You
will still need to pay any Coinsurance, Copayments, and/or Deductibles that apply.) You may be billed
by Your In-Network Provider(s) for any non-Covered Services You get or when You have not followed
the terms of this Benefit Booklet.
2. Precertification will be done by the Network Provider. (See the “Error! Reference source not found.”
section for further details.)
Please read the “Error! Reference source not found.” section for additional information on Authorized
Services.
After Hours Care
If You need care after normal business hours, Your Doctor may have several options for You. You should
call Your Doctor’s office for instructions if You need care in the evenings, on weekends, or during the
holidays and cannot wait until the office reopens. If You have an Emergency, call 911 or go to the nearest
Emergency Room.
45
Introduction
Your health Plan is a Preferred Provider Organization (PPO) for all Members except residents of
Missouri; Members residing in Missouri are part of a Point of Service (POS) Plan. The Plan is divided
into two sets of benefits: Network and Out-of-Network. If You choose a Network Provider, You will receive
Network benefits. Members who are residents of Missouri must use the appropriate POS Network
Provider in their respective states to receive Network benefits. Utilizing this method means You will
not have to pay as much money; Your Out-of-Pocket expenses will be higher when You use Out-of-Network
Providers.
Providers are compensated using a variety of payment arrangements, including fee for service, per diem,
discounted fees, and global reimbursement.
All Covered Services must be Medically Necessary, and coverage or certification of services that are not
Medically Necessary may be denied.
Network Services
When You use a Network Provider or get care as part of an Authorized Service, Covered Services will be
covered at the Network level. Regardless of Medical Necessity, benefits will be denied for care that is not
a Covered Service. The Plan has the final authority to decide the Medical Necessity of the service.
Network Providers include Primary Care Physicians / Providers (PCPs), Specialists (Specialty Care
Physicians / Providers - SCPs), other professional Providers, Hospitals, and other Facilities who contract
with us to care for You. Referrals are never needed to visit a Network Specialist, including behavioral health
Providers.
To see a Doctor, call their office:
Tell them You are an Anthem Member,
Have Your Member Identification Card handy. The Doctor’s office may ask You for Your group or
Member ID number.
Tell them the reason for Your visit.
When You go to the office, be sure to bring Your Member Identification Card with You.
For services from Network Providers:
1. You will not need to file claims. Network Providers will file claims for Covered Services for You. (You
will still need to pay any Coinsurance, Copayments, and/or Deductibles that apply.) You may be billed
by Your In-Network Provider(s) for any non-Covered Services You get or when You have not followed
the terms of this Benefit Booklet.
2. Precertification will be done by the Network Provider. (See the “Error! Reference source not found.”
section for further details.)
Please read the “Error! Reference source not found.” section for additional information on Authorized
Services.
After Hours Care
If You need care after normal business hours, Your Doctor may have several options for You. You should
call Your Doctor’s office for instructions if You need care in the evenings, on weekends, or during the
holidays and cannot wait until the office reopens. If You have an Emergency, call 911 or go to the nearest
Emergency Room.
45
