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Common Questions
Is Physicians Health Plan my healthcare insurance company?
 If your card looks like the
purple card at right, Physicians Health Plan is
your healthcare insurance company. |
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 If your card looks like the
white card at right, 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.
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How do I obtain healthcare
services?
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.
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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 I.D. card at each visit.
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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.
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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.
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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.
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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.
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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
or
e-mail our Customer Service Department at:
custsvc@phpni.com
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