Is Physicians Health Plan my healthcare insurance company?
/If your card has the PHP logo and purple rounded corners, Physicians Health Plan is your healthcare insurance company.
If your card is black and white with your company’s name, Physicians Health Plan is not your healthcare insurance company. Your employer has a self-funded health plan and is financially responsible for payment of your benefits and determines what services are covered and at what benefit level. They have selected PHP Management Systems, Inc. (PHPMSI), a Third Party Administrator and a subsidiary of Physicians Health Plan, Inc., to manage and process medical claims on their behalf. Provider network participation may vary. Please refer to your Summary Plan Description or contact PHP's Customer Service Department for details.
How do I obtain healthcare service?
Your member ID card is your passport to receiving the highest quality healthcare at the most reasonable out-of-pocket cost. Simply present your ID card to a participating doctor or facility at the time services are rendered. Please refer to your Summary Plan Description or call our PHP Customer Service Department for information about your benefits.
How do I use Physicians Health Plan's network provider directory?
This directory lists doctors by their specialty and by city. Please be aware that this information is updated on a regular basis, but a doctor's status sometimes changes. To be certain a doctor is participating, ask the office staff prior to receiving care, or call the PHP Customer Service Department. Always show your ID card at each visit.
Do I need to choose a primary care physician (PCP)?
Primary Care Physicians are defined by PHP as any of the following specialties: Family and General Practice, Internal Medicine, Pediatrics and OB/GYN. We recommend that a Primary Care Physician oversee the healthcare of all members for the best overall quality care; however, Physicians Health Plan's provider network is " open access." Therefore, no referral is needed to see participating specialists.
What should I do in case of an emergency?
PHP's definition of an emergency allows coverage for emergency room services that a reasonable person would consider dangerous to the patient's life or health. If a life-threatening medical condition occurs, call 911 or your local emergency service. If a non-life-threatening emergency occurs, contact your doctor for direction.
It is a good idea to discuss with your doctor what to do in the event of an urgent medical situation before it happens.
What if I need medical care that isn't available from a doctor participating in the network?
A referral to a non-participating doctor may be obtained if a uniquely specialized procedure is medically necessary and not performed by any participating doctors. This process must be requested by your participating doctor and approved by PHP, in writing, prior to receiving the services.
What is PHP's Reasonable & Customary procedure for members enrolled in choice benefit plans?
Physicians Health Plan provides "out of network" benefits for members enrolled in the Choice benefit plans. With out of network benefits, members may use doctors and other health care providers outside of the PHP network. Payment rendered by PHP will be based on language in the member’s certificate of coverage that in most cases requires the amount to be either:
- The In-Network Provider's standard rate adjusted by a geographical factor assigned to the location where the service was rendered; or
- The out of network Provider's eligible billed charge.
PHP utilizes geographical factors established and used by the Centers for Medicare and Medicaid Services (CMS).
By using In Network provider rates and geographical factors, the maximum payment PHP allows for out of network claims will, at times, be less than the amount billed by a provider for a particular service. This may affect the member's out of pocket costs because the member is responsible for the difference between the out of network provider's charge and what PHP pays. This is known as Reasonable and Customary.
How do I get more information?
PHP's goal is to provide quality products and superior service. Questions about benefits, eligibility, claims payment, prior authorization, or the participation status of doctors, hospitals, or other facilities can be addressed by our Customer Service Department.
PHP Customer Service Department
(260) 432-6690, Extension 11
(800) 982-6257, Extension 11
(260) 459-2600 for the hearing impaired
custsvc@phpni.com