Physicians Health Plan provides "out of network" benefits for members enrolled in point of service 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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