WHO IS CONCERT HEALTH PLAN. Physician owned and managed.Re-insurance with HCC the nations largest re-insurer.Fast growing and financially sound.Claims and Customer Service handled locally, not a national distribution center or overseas.A boutique firm that cares about you, our client.. WHAT
1. WELCOME TO
CONCERT HEALTH PLAN
2. WHO IS CONCERT HEALTH PLAN Physician owned and managed.
Re-insurance with HCC the nations largest re-insurer.
Fast growing and financially sound.
Claims and Customer Service handled locally, not a national distribution center or overseas.
A boutique firm that cares about you, our client.
3. WHAT IS A PPO?
4. WHAT IS A PPO? A PPO is a large group of physician, hospital, and ancillary medical providers that contract with a “PPO Network”.
The contract they sign is to offer discounted fees for their services.
As a member of this “PPO Network” you will have access to those discounts, thus saving you and your employer money on your health insurance.
5. IS A PPO DIFFERENT THAN AN HMO?
6. IS A PPO DIFFERENT FROM AN HMO? Yes. In a PPO you do not have a Primary Care provider that tells you where to go for services.
In a PPO you have the control. You can go to any provider you want, whether they are in the network or not.
Unlike an HMO if you go to an “Out-of-Network” Provider you will get some coverage.
However, to fully benefit from the Networks large discounts you need to stay within the network of contracted providers.
Remember: The more you STAY, the more you SAVE.
7. What PPO Networks does Concert Health Plan Offer? HealthLink PPO
Northern Illinois Health Plan (NIHP)
Sagamore PPO Network
Assorted other regional or local PPO Networks.
8. How Do I Find a PPO Provider There are a few ways to find an “In-Network” provider:
Call the phone number listed on the front of your ID card for the PPO Network in which you are a member . They will have the most up to date information for you available.
Go to the Web-site for the PPO Network in which you are a member.
A flyer that came in your enrollment packet has specifics on how to navigate the on-line, web-site look-up that is appropriate for your PPO Network.
9. Understanding your EOB In the upper right Quadrant you will see a box marked “Patient Responsibility”. This will tell you how much you owe and whether or not it is for Co-pays, Deductibles, or Coinsurance.
Directly below that you will see an “Explanation of Benefits”. This will explain how your claim was processed. Among the information cited, It gives you the Date of Service, the amount charged by your provider, the amount not covered, the reason code (we will discuss later), the amount of discount taken, the amount contractually allowed, any deductible or co-pays applied, and the total payment to the provider from Concert Health Plan.
10. Understanding your EOB Below the Explanation of Benefits is the name of the provider, the check number, and the amount paid to them.
4. Below that box is a box titled “Reason Code”: this box identifies why something was not covered. In this example it was 68 for “Patient co-pay” and Reason code 97 meaning the “Contractual Discount” that is not billable to you, the patient.
11. Understanding your ID Card In the upper right hand corner you see the PPO Network that you belong to.
In the upper left is the Concert Health Plan Logo.
In between the Phone number you can call to find an “In-Network” provider.
12. Understanding your ID Card In the middle you can find your Group name, Employee name, your ID number, and your dependent coverage (single, family, etc.).
Directly above the Customer Service phone number will be your office visit co-pay and your Rx co-pay amounts.
13. Understanding your ID Card At the bottom of the card are important phone numbers to know. Customer Service, Utilization Review, and the number to Caremark, our prescription drug provider.
14. Understanding your ID Card The back of your ID Card has very important information for you to know. For Instance:
Utilization Review information and contact numbers. If we are not notified accordingly, your benefits may be reduced.
The phone number for VSP our vision care provider.
And, of course, where the provider can send your claim to get reimbursed.
15. What is Pre-Certification? In your “Certificate of Coverage” there are listed many different procedures and services that are needed to be pre-certified.
Pre-certification notifies Concert Health Plan when you are having any of these services so we can monitor your progress and to make certain that the provider understands your benefits.
Failure to “Pre-certify” may reduce your benefits.
16. How do I fill a Prescription? You have 2 ways to fill your prescriptions.
Go to any of the major chain pharmacies (and many local, non-chain pharmacy) that contract with Caremark.
Contact Carmark at the 800 number on your ID Card to see how you can save even more money when you utilize their “Mail order” prescription program.*
* (Many plans have a mandatory use of the “Mail Order” program for maintenance drugs. See your Certificate of Coverage for details)
17. When do I go to the Emergency Room? That is simple: Whenever you feel you have a life threatening emergency!
There is a co-pay associated with your use of the emergency room. (This is usually between $100-$150)
The ER co-pay will get waived if you are admitted to the hospital.
18. When do I NOT go to the Emergency Room? Any time you are ill, but are not emergent.
It is most cost effective for you to go see your “In-Network” physician. When you see your physician at their office you only pay your Office Visit Co-pay (usually between $20 and $50)
In the alternative, you can go to an “In-Network” Intermediate /Immediate Care Center. Many hospitals offer these free standing facilities that accept walk-in visits and visits by appointment. When you utilize these “In-Network” centers, you pay your Office Visit co-pay. This is substantially less than an Emergency Room Co-pay, and your wait time is significantly less.
19. Frequently Asked Questions My son/daughter goes to school in another state. How do I find a provider for him/her?
Concert Health Plan has partnered with your PPO Network for your health plan. In order to locate a provider, simply go to the web site for your PPO Network.
To reduce your personal healthcare cost, always confirm with the PPO Network that the provider is still participating in the PPO Network at the location you have chosen.
20. Frequently Asked Questions My provider is not in my PPO network. How do I get them in the network?
Please call your PPO Network. The PPO representative will take the provider’s information and will contact that provider directly. It typically takes 90-120 days for a provider to go through the entire process and join a PPO network.
What if I lose my card or need additional ID cards?
Simply contact Concert Health Plan’s Customer Service department toll-free at 866-818-3106 and they will be happy to assist you.
21. Customer Service If you are unsure of how your plan works or the benefits you have, you first should go to your Certificate of Coverage and read up. Educating yourself on the benefits and limitations of your plan is the best way to maximize your benefits.
If you still are unsure, please call our Customer Service line @ 1-866-818-3106 and ask our trained and caring Customer Service Representatives how they can assist you.
22. Educate Yourself and Take Control of Your Healthcare! Always try to utilize “In-Network” providers. They will save you money.
The best advice we can give you is to “Read your Certificate of Coverage and the other material you are given”!
The better you know your benefits and limitations, the more you can maximize your savings and reduce your out of pocket costs.
23. THANK YOU FOR CHOOSING CONCERT HEALTH PLAN. WE LOOK FORWARD TO GIVING YOU GREAT SERVICE!