PPO stands for Preferred Provider Organization. In a PPO, members enjoy the freedom to see any physician or other health care professional from the network of participating providers, including specialists, without a referral. With a PPO, your out of pocket expense will be significantly less if you access care from "participating" providers. In addition, you do not have to worry about any claim forms or bills.

You may also choose to seek care outside the network, without a referral. However, you should know that care received from a non-network physician, facility or other health care professional means a separate and higher deductible, co-insurance, and co-payment. In addition, if you choose to seek care outside the network, the health plan only pays a portion of those charges (based on Reasonable & Customary Fees for those services) and it is your responsibility to pay the remainder, including any amount above and beyond Reasonable & Customary Fees for those services. We recommend that you ask the non-network physician or health care professional about their billed charges BEFORE you receive care.

No - you do not have to select a primary care physician (PCP), there are no referrals, and you choose either in-network or out-of-network providers. Of course when you stay in-network, you'll get the highest level of benefits for the lowest cost.

No - you do not need a referral whether you are using in-network providers (commonly referred to as “Participating Providers”) or you are using out-of-network providers (commonly referred to as “Non-Participating Providers”). You will never need a referral.

You can visit another provider without a referral for a second opinion.  For maximum savings, visit an in-network doctor.  Normal co-payment, co-insurance, and prior-authorization requirements apply for the second opinion services any diagnostics the second-opinion provider requests.

Yes, you are still covered when you go out of network, but your out of pocket costs will be significantly higher than if you stayed in network. No referrals are needed, however, you may have to pay for services received and file a claim for reimbursement. Some out of network doctors will file the claims with the insurance companies for you - and some will make you pay them in full and file for reimbursement on your own. It all depends on the doctor.

If you choose to use a non-network provider, you will be subject to the plan's separate and higher non-network deductible and coinsurance. Out of network fees are also subject to allowable (reasonable & customary) charges. This means that if your out of network doctor charges higher amounts than the allowable amount, YOU will be responsible for any charges in excess of the allowable charges, in addition to your portion.

Understanding Allowable Charges
The Allowable Charge is the amount on which deductible and coinsurance amounts for eligible services are calculated. Participating providers have agreed to accept fees established with the provider (called network allowance, reasonable and customary, or participating provider allowance) as payment in full. When you seek treatment from non-participating providers, there may be a difference between the allowance and the provider's regular charge or a balance you are responsible to pay. By using participating providers, you can avoid these extra charges.

You can access your online provider directory here. If you do not have access to the Internet, you can call member services using the number on the back of your ID card and have an experienced healthcare professional guide you.

Yes. Always. All non-emergency hospitalization stays require pre-authorization. Always make sure either you or your doctor calls your insurance company to verify benefits and to pre-authorize your hospital stay. If you fail to pre-authorize, there is a financial penalty and the health plan will pay for a much smaller portion of your hospital stay. Your costs will be lower when you use an in network hospital and your stay has been pre-approved.

In cases of emergency when you don’t have time to pre-certify, make sure to call Member Services at your insurance company within 48 hours and notify them of your hospitalization and applicable medical situation.  The phone number is on the back of your insurance card.

In an emergency, always seek medical care immediately. Go directly to the nearest hospital or call 911. You are not required to obtain prior authorization from your insurance company before receiving emergency care, but if you are admitted into the hospital or receive any type of service that normally would require pre-authorization, you should call your insurance company (or have someone call for you) within 48 hours or as soon as reasonably possible to report the emergency and receive any further assistance or follow-up care.

Examples of emergencies include:

• Uncontrolled bleeding
• Seizure or loss of consciousness
• Severe shortness of breath
• Chest pain or severe squeezing sensation in the chest
• Poisoning or suspected overdose of medication
• Sudden paralysis or slurred speech
• Severe burns
• Severe cuts
• Severe pain
• Broken bones

If you are unsure if a medical situation constitutes an emergency, you may call the Nurse Advice Line for guidance.  The phone number is on the back of your insurance card.

Emergencies
These are sudden and unexpected illnesses or injuries in which loss of life, limb, or severe and permanent medical complications could result if care is not received immediately. Some examples:

• Loss of consciousness
• Uncontrolled bleeding
• Inability to breathe or severe shortness of breath
• Poisoning or suspected overdose of medication
• Severe burns
• Chest pain or oppressive squeezing sensation in the chest
• Numbness or paralysis of an arm or leg
• Suddenly slurred speech
• Lack of responsiveness
• Seizures

If you see any of these symptoms, get medical attention immediately!

• Go to the nearest emergency room
• Call your area's emergency services number or 911
• Call your doctor

Urgent Care
These are situations that require prompt medical attention, but are not considered emergencies. Some examples:

• Ear infections
• Excessive vomiting
• High fever
• Minor burns
• Sprains
• Urinary tract infections
• Prolonged diarrhea

If any of these symptoms are present, call your doctor. He or she will direct you to the most appropriate type of care — emergency room, urgent care center, or office visit. Your doctor may also prescribe medications that will make you more comfortable.  You may also call the 24-Hour Nurse Advice Line for guidance on whether or not a medical situation is an emergency.  The phone number is on the back of your insurance card.

Participating PPO providers will file the claims for you. Your PPO plan will determine benefits based on the health plan's benefit design, and payment for covered services will be made to the doctor or to you based on the information the insurance company receives. You can call Member Services at the toll-free number on your ID Card to check the status of a claim, or visit the UMR portal to look for your Explanation of Benefits (EOB) related to the services you received. Non-network doctors do not have to file your claims for you. Some of them will and some of them will not – it depends on the (out of network) doctor.

Remain calm – this is just an administrative error and it can be corrected within 1-2 business days. Rest assured that if you are signed up for coverage through your employer and are paying for benefits, that you definitely have coverage. Administrative errors happen in all businesses and it is easy to correct. Simply check with the COH Benefits Team at (702) 267-1944 or MyCOHBenefits@cityofhenderson.com, and ask them to make sure you are enrolled correctly into the system. As soon as the administrative error is corrected, you can call the insurance company and have your claims reprocessed with no problem, or go back to the pharmacy to get your prescription filled!

You can visit the UMR portal to order a new insurance card, or call Member Services and request a new ID card to be sent to your home.  The phone number is on your insurance card.  UMR will allow you to print temporary ID cards from their portal.  When you log in to the UMR portal, be sure to verify that they have correct information on file such as addresses, telephone numbers, the correct members enrolled, etc.

All doctors' offices work differently – so try one of the following approaches:

1. Have the doctor try calling member services and identifying you with the social security number of the primary insured (primary insured will be the employee of the company providing your group health benefits). Even if you do not have a card, they can usually verify benefits for the doctor based on the primary insured’s social security number and allow you to receive care.
   
   
2. Explain to the provider that there is an administrative error in your insurance company’s system that will be corrected within 1-2 business days and have the provider file a claim (via the mail) with your PPO Plan. By the time the claim form is received by your PPO Claims Department, your specific information should be updated and the provider will be reimbursed according to the correct benefit level. Remember that all insurance is tracked by the employee’s social security number and the employer’s group account number.
   
   
3. If the doctor will not do #1 or #2, then call COH Benefits for assistance at (702) 267-1944 or via e-mail at MyCOHBenefits@cityofhenderson.com.
   
   
4. If any of this happens at a pharmacy, you may have to pay for the claim out of pocket and file for reimbursement, or wait 1-2 business days until the administrative error can be cleared up and then go back to the pharmacy and pay the regular pharmacy copay.
   
   

1. Make sure that you contact your insurance company first by calling member services using the number on your ID Card. Ask the customer service representative to help you understand why the claim was paid incorrectly.
   
   
2. Make sure to write down the person's name and ask them if your call is being tracked so that if you ever have to call again, there is a record of the conversation and the information they are giving you!
   
   
3. Confirm that you and your family are enrolled properly into the insurance system.  If there is a problem with your basic enrollment information, contact COH Benefits at (702) 267-1944 or MyCOHBenefits@cityofhenderson.com to request them to correct it for you.
   
   
4. Once the administrative error is fixed, you can call the insurance company again (when they can see your correct information) and ask them to re-process your claim. This usually works!
   
   
5. If there is no resolution after calling customer service, get copies of all related paperwork including claims, bills, collection notices, EOB’s (Explanation of Benefits) and anything else that is relevant and ask the Benefits team to assist you.  Keep copies of EVERYTHING in case you ever have to contest a credit rating problem as a result of a collection issue. If you are proactive and address these issues right away, then 99% of the time the issue can be resolved before it goes to collection.

Open enrollment will occur once a year from November 1st - November 30th.  Each year during this Open Enrollment period, you may change your benefit elections. Once you have made your selection, you may not change it until the next year's open enrollment unless you have a qualifying life event (QLE).  QLE's include:

• Marriage
• Divorce or legal separation
• Birth
• Adoption or legal placement of a child
• Death
• Spouse losing coverage at their place of employment
• Child losing coverage due to reaching the age limit

You must notify the Benefits team in writing within 30 days (90 days for birth of a child) to request a change in your benefit elections.  Benefits will need the reason for the change, appropriate documentation, and the effective date of change.