What is Perferred Health Care (PHC)?
PHC is a Preferred Provider Organization established over twenty years ago to provide you with cost-effective healthcare delivered by high-quality physicians and hospitals. PHC partners with your providers and Insurance Company / Third Party Payor (TPA) to provide discounts for services. We offer Medical Management and Case Management programs to support you when specific medical care is required. We follow NCQA (National Committee on Quality Assurance) standards when credentialing our providers. Our Quality Management committee periodically reviews established patterns of care and quality to help you receive appropriate medical services. Our network includes:
- Hospitals, Ambulatory Surgery Centers, Outpatient Dialysis Centers, Cancer Centers
- Home Health Care, Skilled Nursing Facilities and Hospice
- Cardiac and Pulmonary Rehabilitation
- Diagnostic Testing – Laboratories, Pathology and Radiology
- Physical, Occupational and Speech Therapy Centers
- Mental, Behavioral, Drug and Alcohol Rehabilitation Centers
- Medical Equipment Suppliers, Audiology
- Wellness Programs and Fitness Centers
- Primary Care (Family), Pediatric Primary Care, Internal Medicine, and Geriatric
Why is there an Insurance Company / Third Party Payor (TPA)?
The Insurance Company / Third Party Payor (TPA) is the company that sends payment to your health care provider. They also provide patients and health care providers with information regarding your allowable benefits as established by your employer health coverage contract. You will receive your Explanation of Benefits (EOB) from the Insurance Company / TPA.
The EOB will detail:
- The Provider Charge
- The discounted portion of the charge(s)
- The amount you paid for the office visit co-payment (if applicable)
- Any amount applied to your deductible
- The amount paid to your provider by the Insurance Company / TPA
- Any amount you still need to pay the provider
May I choose my own doctor?
Yes! You may choose any physician from our Directory of Participating Providers. You may choose an out-of-network provider, but your out-of-pocket expenses will be greater. You must contact your Insurance Company / TPA for out-of-network benefits. The telephone number is on the back of your insurance card.
Do I need a referral to see an In-Network Specialist?
No. You may go to any participating specialist of your choice. Please refer to our Directory of Participating Providers.
Do I need a referral or approval for an Out-Of-Network Hospital or Physician?
No. Please contact your insurance company / TPA to determine your out-of-network benefits and the additional expense you may incur. You will also need to contact PHC Medical Management to verify pre-certification requirements.
How will my physician or hospital know I belong to PHC?
Your employer will provide you with an identification card which you must present whenever you receive services from a health care provider. Always make sure you use your most current insurance card.
When do I pay my co-payment (if applicable)?
Your co-payment is payable at the time of service. If your insurance coverage requires a co-payment it should be indicated on your insurance card.
When do I pay more than a co-payment?
When you receive your Explanation of Benefits (EOB) it will indicate any money amount you are responsible to pay your physician.
What is a co-insurance amount and is it my responsibility?
A co-insurance amount will reflect the portion of coverage that you are responsible to pay. This amount is over and above a co-payment. For example, your employer’s health plan benefit may cover 90% of allowable charges and your responsibility will be the balance of 10%. You will need to check with your employer and Insurance Company / TPA to determine that amount. Any co-insurance amount due will be included on your Explanation of Benefits (EOB).
I believe my claim was processed incorrectly, or I have a question about my health plan benefits. Who do I call?
Please contact the Insurance Company / TPA listed on the back of your insurance card if you have any questions. PHC applies our network discount to the charges submitted by your provider and forwards the claim to your Insurance Company / TPA for benefit determination and payment.