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Patient Choice Insights
Frequently Asked Questions and Answers
Q. What do the tiers represent?
A. In general, you will receive a higher (or better) level of in-network benefits when you obtain care from a participating provider who is in a lower tier.
For some services, the in-network benefit level does not vary depending on your provider’s tier. These services are identified as “non-tiered” in your Summary Plan Description. For example, preventive services are sometimes covered at 100 percent, in which case, you would receive that level of benefits for preventive services regardless of your provider’s tier. In other words, your coverage would be the same whether you visited a tier 1, tier 2 or tier 3 provider.
While you receive the same level of benefits for non-tiered services, regardless of the provider’s tier, the information is still important because your employer will pay the varied costs. You can help your employer manage health care expenses by considering cost group information when making decisions about your care.
Your Summary Plan Description includes detailed information about the benefit levels available for tiered and non-tiered services.
Q. How are providers tiered?
A. Primary care providers are grouped into the health care organization with which they are affiliated and tiered on cost, quality and efficiency measures. The tiering process takes into account their price, the price of the specialists and hospitals they use, and their ability to effectively manage patient care—especially for patients with chronic illness.
Specialty care providers are tiered on price, combined with their clinic’s systems and/or special programs that can lead to improved quality and better patient outcomes.
Hospitals and other outpatient facilities are tiered on their overall pricing, combined with their performance on nationally accepted quality standards including the Leapfrog Group and National Quality Forum measures.
Q. Do providers change tiers?
A. Yes. Each year, network providers are analyzed on cost, quality and efficiency measures and placed into tiers. As a result, providers may change tiers from year to year. The new provider tier information becomes effective on January 1 each year.
Prior to the new year, the new tier information is available on the Patient Choice online directory.
Q. How do I access services in-network?
A. You may directly access care from any provider participating in the Patient Choice Insights network, to receive your in-network level of benefits. The benefit will be determined by the tier of your servicing provider.
In general, you receive the higher (or better) level of in-network benefits when you obtain care from a participating provider that is in a lower tier.
Q. What if I see a provider who is not part of the Patient Choice Insights network?
A. Services furnished by health care providers and facilities that are NOT part of the Patient Choice Insights network are considered “out-of-network” services. Your out-of-pocket expenses will be higher for out-of-network services. Depending on the benefit plan offered by your employer, out-of-network services may be covered at a reduced benefit level, or may not be covered at all. See your Summary Plan Description or call Customer Service at the telephone number listed on your identification card for more information.
Q. Is a provider in a lower tier always the best choice?
A. Not necessarily. Just as you consider many factors when making other purchasing decisions, the lowest priced option may not best meet your needs. Considerations such as special expertise, experience with your condition and convenience are just a few examples of other factors to weigh in your decision-making.
Q. My provider is interested in becoming part of the Patient Choice Insights network. What do they need to do?
A. Provider’s can contact Patient Choice to discuss possible contracting arrangements.
Q. What is the difference between tiered and non-tiered benefits?
A. For benefits that are tiered the amount of your copayment/coinsurance varies by provider’s tier. For non-tiered benefits the amount of your copayment/coinsurance will not vary depending on the provider’s tier.
Q. What is the Hospital and Outpatient Surgery Facility Guide and Pricing Catalog?
A. This guide gives members information about the tools and resources available when choosing a facility. It includes details about the compare hospital quality tool, a Facility Pricing Catalog, a list of Important Resources and also provides a set of questions individuals should ask when choosing a hospital.
Q. What kind of information is available in the Facility Pricing Catalog?
A.The Facility Pricing Catalog is featured in the Hospital and Outpatient Surgery Facility Guide. It includes actual contracted facility pricing for 15 selected procedures at some of the area’s prominent network hospitals and outpatient surgery centers.
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