Frequently Asked Questions

What is a PPO?

A PPO is an organization of physicians, hospitals and ancillary providers that have agreed to care for patients at pre-negotiated rates and participate in utilization management programs. The providers and hospitals listed on-line in the PHCS directory are those that have agreed to provide discounts when you use their services. Providers do move in and out of networks. To ensure you receive discounts, make sure your provider is still in the network. Always identify yourself as a PHCS participant. If you are referred to another physician, or other ancillary service, ask if they belong to the PHCS Network. If you are referred to a lab, ask if they belong to the PHCS Network. Most doctors’ offices are aware of your level of benefits and will try to refer you to other network physicians, hospitals and ancillary service providers, but it is your responsibility as an informed consumer to ask the questions necessary to receive the best level of benefits and save your company health care dollars!

What does "In-Network" mean?

When a participant uses services of contracted network providers, the benefits received are paid at an "in-network" level. When a participant uses non contracted providers, benefits are reimbursed at the "out-of-network" level.

What determines if I am "In-Network"?

If you live within 50 miles radius of a network provider, you are considered "in-network". Benefits will be paid at the 50% of Reasonable and Customary if you choose hospitals that are not members of the network. There is no limit to the out- of-network limits.

What is a "co-pay"?

In your benefit plan a co-pay is the dollar amount ($20.00) that you pay for an office visit to a network physician. This co-pay covers most covered eligible services that are administered in the physician's office. If the physician sends you to an outside lab for tests or x- rays, be sure to ask the physician's office if this charge will be separate from the physician's charges. If so, be advised that the deductible will apply and benefits will be paid at 80% if the provider is not on the network. A non-network provider will not accept co-payments. Also, using a network provider for your physician visit makes claim filing easier on you! The provider will file the claim for you. There are also other co-pays in your benefit plan. There is a $50.00 co-pay every time you use an ER and are not admitted and a $30 co-pay when you use an out patient facility. A $100.00 co-pay is charged for every hospital admission.
What can I do to use my Network to the best Advantage?

Choose network providers and save yourself and your company health care dollars. Call the provider’s office and confirm that they are on the network. Identify yourself as a PPO participant. Always present your ID card to the provider. Be sure that they have your employer's name and use that name on your claim forms. Keep your benefit information up to date at the providers' offices. Periodically check all the information with the physician's office. This will help you receive the most efficient service and reduce claim delays from both the network and your claims processor.

What if I'm out of town and need to see a physician?
What about my Student Dependent in another city?

Your managed care network is a national network. There is atoll free number: 1-888-719-7427 that can direct you to a network provider of services when you are out of town. It is on the front of your ID card. However, if it is an emergency or there is no network provider in the area, your benefits will be paid according to the specifications in your Plan Document. Your Plan Document will provide requirements necessary to obtain "out-of area" benefits, these benefits are paid at 80% (deductible and co-insurance apply). It is your responsibility to notify Boon-Chapman @ 1-800-211-2136 if you require “out-of-network” benefits. If your dependent is a student, be sure they know which provider they should access that is "in-network". Also, you should have a student verification form filled out every semester and sent to Bridge-Works to ensure benefit eligibility continuation.

Emergencies Go to the nearest physician or facility for medical attention. If the service rendered requires pre-certification, have the provider pre-cert with PHCS Network. As soon as you are able, report the medical service to Boon-Chapman or Bridge-Works. A note will be entered into the system and your claim will be paid at “Out of Area” benefits. This will facilitate your claim and have it paid accurately the first time!

How Can I get My Claim Paid Quickly?

Be sure your provider has your current benefit information.
If there is any change in any family members important information, such as student status, spouse’s change of employment, other insurance coverage’s, accidental injury, etc., notify the HR Department immediately! Make sure your spouse is using the name under which she is covered.
Accident claims will not be paid unless you have filled out an accident report and faxed it to bridge-Works. Your HR department has the accident forms for you to fill out.

Don’t send a receipt or statement from your physician or hospital showing only “balance due”. The claims payor cannot pay the claim from this type of billing.

Do not disregard EOBs. These Explanation of Benefits tell you why and how a claim was paid or not paid. There are reason codes that have explanations in the middle of the forms that tell you why a claim was denied. It will say that they need more information. Maybe the charge went to your deductible. An explanation of how to read an Explanation of benefit is in another Section on this website.