In-Network Coverage/Out-of-Network Coverage
How Benefits Are Paid
The PPO Plan features a network of selected providers who have agreed to provide medical care at a fixed rate for plan participants.
If you prefer, you can use a provider from outside the PPO network. You make this choice each time you need care.
For In-Network and Out-of-Network coverage, the plan pays a percentage of eligible charges for covered expenses after you pay a certain amount. Amounts are based on services which could include coinsurance, copays and annual deductibles. You are protected from catastrophically high expenses through the plan’s out-of-pocket maximum, which limits the amount you and your family have to pay for covered expenses in a given year. For more information, see “Your Health Care Options at a Glance” in the Your Medical Plan section.
Call for Pre-Certification
You must pre-certify certain kinds of care by calling the medical utilization company in advance, at the number listed on your benefit card.
If you have questions about what kinds of services need pre-certification, you can call Pequot Plus Health Benefit Services at 1-888-779-6872.
Pre-Certification
If the plan requires pre-certification for a service and you or your doctor fail to pre-certify that service, you will be financially penalized. The penalty is 20% up to $5,000 per cause. (“Cause” is defined by the PPO Plan as a continuous treatment prescribed within a clinical treatment plan for a specific diagnosis.) Be sure you understand that pre-certification alone doesn’t mean your care is covered — pre-certification is just a first step, and not a guarantee that benefits will be paid. After pre-certifying your care, the plan will still have to review your claim to determine what benefits, if any, are payable.
You must obtain pre-certification, or advance approval, for certain kinds of health care. Pre-certification is designed to help protect you from the cost and inconvenience of unnecessary surgery or extended hospital stays. By calling for pre-certification, you learn before you incur an expense whether your treatment is medically necessary. (If the treatment is not medically necessary, the plan will not pay any benefits for that treatment.) In addition, it is important to pre-certify when the plan requires it. If the plan requires pre-certification for a service and you or your doctor fail to pre-certify that service, you will be financially penalized. The penalty is 20% up to $5,000 per cause. (“Cause” is defined by the PPO Plan as a continuous treatment prescribed within a clinical treatment plan for a specific diagnosis.)
The Complete List of Services
The list to the right provides examples of the services requiring pre-certification. To find out whether the list has changed and whether the health care you are seeking requires pre-certification, you or your health care provider should be sure to contact the medical utilization company at the number listed on your benefit card or call Pequot Plus Health Benefit Services at 1-888-779-6872 in advance.
The pre-certification program for the MPTN Health Care Plan is managed by a medical utilization company. You must pre-certify by calling the number listed on your benefit card in advance. Examples of services requiring pre-certification are listed below and are not inclusive of all services needing pre-certification. The list of services requiring pre-certification is subject to change at any time.
- All inpatient services
- Cosmetic procedures (e.g., reduction/enhancement mammoplasty, rhinoplasty, abdominalplasty, etc.)
- Varicose veins — stripping and ligation
- Durable medical equipment (rentals over $500.00; purchases over $1,000.00)
- Home health care
- Inpatient and partial levels of care for behavioral health and substance abuse services
Properly Completed Claims Speed a Response
There are a few things you can do to ensure that your claims are processed quickly and accurately. When you visit a doctor, hospital or other medical provider, be sure to ask for an itemized bill that includes:
- the name of the patient,
- the name of the provider,
- the nature of the medical or surgical procedures and other services and supplies furnished,
- the date, and
- the amount charged for each procedure.
If Your Request for Pre-Certification Is Denied
If your pre-certification request is denied, you may appeal. You may also appeal if your request for benefits is denied.
The medical utilization company has a multi-level appeals process. You and your provider are able to participate in all levels in an attempt to reach resolution. If your treatment is denied during the pre-certification process, you should encourage your provider to become involved and to request an appeal.
Often, the original denial is merely the result of not enough medical information needed to approve your claim. If you supply the additional information and the pre-certification is still not granted, your doctor may request a physician-to-physician review.
Filing a Claim for Benefits
Here is the way you claim benefits under the PPO Plan:
- See your doctor or other health care provider. Generally, both in-network and out-of-network providers will submit your claim to the plan directly.
- If your out-of-network provider does not submit your claim for you, you pay in full for all services received and file a claim with MPTN. Your claim must include an itemized bill showing the name and address of the patient, the name of the team member, the services rendered and the amount paid.
- The plan will reimburse a percentage of eligible charges once you meet the deductible for the year.
- If you reach the annual out-of-pocket maximum, the plan then pays 100% of most covered expenses that you incur during the rest of the plan year.
For More Information …
… on appealing a claim, see “Claims Review and Appeals Procedures” in the Rules and Regulations section
When to File a Claim
To be reimbursed, you must submit your claim within one year of the date when the service for which you are claiming benefits was provided. For example, if you receive care on October 4, 2011, you must submit your claim for benefits for that care no later than October 3, 2012.
Not Sure Whether Your Expense Is Covered?
If you don’t see a particular service listed in this section, check the list of excluded services under “What’s Not Covered” in the Your Medical Plan section.
If you don’t see the service listed here or under “What’s Not Covered,” call Pequot Plus Health Benefit Services at 1-888-779-6872 to determine coverage.
If You Are Enrolled in a Health Care Flexible Spending Account
If you are enrolled in a Health Care Flexible Spending Account, you must submit copies of your bills for reimbursement directly to:
Pequot Plus Health Benefit Services
Health Care Flexible Spending Account Administrator
P.O. Box 3620
Mashantucket, CT 06338-3620
1-888-779-6872
For more information on Health Care Flexible Spending Accounts, see the Flexible Spending Accounts section.