Frequently Asked Questions

After enrolling you will receive an ID card and benefit guide in the mail. Please allow up to 15 business days to receive your new card in the mail.

When you need care but don’t yet have your ID card, there are a few things you can do:

• Log in to your myPRES account and select MyIDCard to print, fax or email your ID card.
-OR-
• If you are at our provider’s office they should be able to access your health plan information with your social security number.

You could be terminated for non-payment of premium and only be able to apply again for insurance during the open enrollment period or special enrollment periods.

No. See question 1 for information on premium billing and the monthly premium draft.

If you feel you may have been charged incorrectly or you have premium billing questions please call the Presbyterian Customer Service Center

For detailed information on individual plans, refer to Understanding Health Insurance

No. You can change your plan only during the open enrollment period, which begins on October 1. If something changes in your life (for example, marriage, the birth of a baby, etc.) you may be able to change your coverage. See the next question below.

A change in your life can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events include moving to a new state, a change in your income, and changes in your family size (for example, if you marry, divorce, or have a baby). Another example is if you were covered under an employer plan and you lost your job.

To add your spouse and/or dependent, you will need the following required paperwork:

1. Qualifying Event or Move Dependent Form
2. Proof of qualifying event (e.g., birth certificate, marriage certificate, loss of coverage, etc.)

To request to add a newborn, newly adopted child, or new guardianship of a child, send us the Add Dependent form and a copy of a document that shows proof of date of birth or a legal document such as a birth certificate. To have your child added to your plan retroactive to the date of birth, adoption, or guardianship, the document of proof must show the date of birth or the date of placement for adoption/guardianship within 31 days from the event for Individual and Family plans and 31 days for employer plans.

Medical premium rates on an Individual Health Plan are based on insurance pooling. This means that individuals incurring lower claims help subsidize (pay for) individuals who have significantly more claims. Premium rate increases are determined by looking at the total claims for all the Individual plan members within all benefit options and then dividing by the total number of covered members for the recent twelve-month period. The results are the claims per member per month. The claims are then adjusted forward from the last 12 months to the renewal period to cover expected future costs.

Increases in claims costs have many causes:

• Increases in charges for medical services
• Increases in use of medical services
• Aging of the population
• Increased use of new drugs, technologies, and procedures
• Inefficient use of services, such as the use of the emergency room when a doctor-office visit would have been effective treatment

Most Presbyterian health plans offer prescription drug coverage. Refer to your Summary of Benefits and Coverage by logging in to myPRES to see if you have this benefit. It is you and your doctor’s responsibility to make sure that your drug is listed on the Presbyterian approved drug formulary (list). You can learn more about formularies by visiting Presbyterian’s Pharmacy Resources webpage.

Covered medications, both generic and brand-name, are listed in a prescription drug formulary or drug list. Most major drug classes are listed. If your prescribed medication is not on this list, you and your doctor may work together to submit a prior authorization to see if you meet criteria for coverage of a non-formulary drug.

A prior authorization is a process between your doctor and the health plan to obtain advance approval of coverage for a prescription drug. Some prescription drugs require your doctor to provide more information about your prescription to determine coverage.

If you think you need a prior authorization, talk to your doctor first. He or she can initiate the prior authorization review with Presbyterian Health Plan. If you would prefer, you can also initiate the prior authorization process yourself.

Learn more about your plan’s drug coverage and how to initiate a pharmacy exception request

To find out if your drug is covered through Presbyterian, you can:

• Visit the Pharmacy Resources webpage to review your plan's drug coverage
-OR-
• Call the Presbyterian Customer Service Center to ask if it is covered

Many medications can be used for multiple medical purposes, so it is important to ensure that the best drug is being used to benefit the patients’ needs. Prior authorizations allow doctors to make that determination. Drug effectiveness, drug safety, and established clinical guidelines are the baseline criteria for determining if a prior authorization will be granted.

For assistance with Prior Authorization or Utilization Management issues please call the Presbyterian Customer Service Center, during and after normal Business hours. We also offer translation and interpretation services to translate and interpret healthcare information in more than 160 languages. When you call customer service, ask to be helped in the language that you need.

If your drug is not listed on your copy of the Presbyterian formulary, you may contact the Presbyterian Customer Service Center to be sure it isn’t covered.

If the Presbyterian Customer Service Center confirms that we don’t cover your drug, you or your doctor may ask us to make a pharmacy exception. This means asking Presbyterian to cover your drug or waive limits on your drug. If we agree to make an exception, you may have more out-of-pocket costs.

Learn more about your plan’s drug coverage and how to initiate a pharmacy exception request

Tip 1: Read your Presbyterian formulary by going to the Member Download Library. If your drug is not listed on the drug list, talk to your doctor to see if your medication can be substituted. It could save you money.

Note: Depending on your health plan type, you will also want to learn about your prescription benefits and cost-sharing information and how it applies to prescription drugs. This will help ensure that you are not caught off guard when it comes time to fill a prescription.

Tip 2: Consider generic drugs. Generic drugs are regulated by the U.S. Food and Drug Administration (FDA) and have the same active drug ingredients, safety, performance, quality, and strengths as brand name drugs. Talk to your doctor or pharmacist if a generic equivalent is available for you. You can learn more about generic drugs by visiting the FDA Generic Drugs Questions and Answers web page.

Tip 3: Take advantage of Rx Home Delivery. Your prescription benefit includes the use of OptumRx Prescription Mail Service. Choosing mail service allows you to enjoy delivery of your maintenance medications to the location of your choice—it’s easy, convenient, and can save you time and money. The benefits of mail service include:

• Easy registration and ordering
• Quick delivery of medications in confidential, tamper-evident packaging
• Free standard shipping
• Important medication information included with every order
• Access to a clinical pharmacist 24/7
• Auto-refill option
• Online account management and support
• Lower cost-sharing for some members

Learning how much a drug will cost and searching for less expensive alternatives ahead of time can save you money. You can log in to your myPRES account and select Manage My Prescriptions, which allows you to:

• Check your prescription benefits and copayment
• Register for mail-order prescription delivery via OptumRx Mail Service
• Find pharmacies in your area
• Find out about your medications and possible side effects
• Check your medication history
• Access the Member Reimbursement Form
• Get information what to do if your medication is not covered

When you receive care from a provider, the provider submits a medical claim form to Presbyterian Health Plan for reimbursement. The medical claim contains details of the services provided including the charge amounts for each of the services. Presbyterian Health Plan will process the claim according to your health insurance benefits and regulatory guidelines. An EOB is generated after the claim has been processed and provides a record of the services processed according to your health insurance. An EOB displays the following information:

• Service Dates: Identifies the date of service.
• Services Provided: A description of the medical service.
• Amount Billed: The amount the provider charged for the service.
• Amount Allowed: The amount Presbyterian Health Plan allowed for the service.
• Copayment or Coinsurance: The copay and/or coinsurance amount you are financially responsible for.
• Deductible: The deductible amount you are financially responsible for.
• Amount Paid by Plan: The amount Presbyterian Health Plan reimbursed the provider.
• You May Be Billed: The amount you are financially responsible for.
• Codes: The explanation codes provide detail about how the claim was processed according to your plan coverage. A description of the codes is located under the Code Message Description section of the EOB.

You can log in to myPRES to access your claim information. Select the claim in question and you will see an explanation for each code at the bottom of the page.

There are many reasons why a claim could be denied. Common reasons include a provider submitting insufficient information needed to process the claim, or visiting an out-of-network provider without first obtaining a prior authorization. If you have any questions about the denial of a claim, please call the Presbyterian Customer Service Center using the phone number located on the back of your Presbyterian ID card or at info@phs.org.

An adjustment may be performed when Presbyterian Health Plan determines that a claim was processed incorrectly or when a provider submits a corrected claim. Depending on the corrections, Presbyterian Health Plan may pay more money on a claim or recover amounts that have been overpaid. Contact the Presbyterian Customer Service Center if you have questions about why an adjustment was made on a claim and if you may have a financial responsibility.

If you feel you may have been charged incorrectly for medical services, here are some steps you can take.

• Call the Presbyterian Customer Service Center or the facility where your services were rendered to inquire about the charges. If you are disputing an incorrect claim, you can request a complete copy of all medical services you were billed for. You can also request an inquiry to be made into the claim.
• Collect any documentation related to the charges.
• Once you receive the results of the inquiry, if you are not satisfied with the results, you can request a meeting with Presbyterian Health Plan to discuss the inconsistency.
• If you were working to have a service covered when the coverage was denied, you will need to talk to both the doctor and Presbyterian Health Plan. The cause for the denial could be as simple as encoding error and may be able to be corrected quickly.

• Make sure that all procedures that require pre-authorization have received authorization to avoid any billing issues. Generally, the doctor will take care of this, but you can double check before the procedure by contacting the Presbyterian Customer Service Center at the number on the back of your ID card.
• Sometimes a hospital is on the Presbyterian in-network list, but some of its doctors may not be. Be sure to ask about this to ensure you are staying in-network for all your medical services.

A reasonable (or usual) and customary fee is the amount that your health plan determines is the normal range of payment for a specific health-related service or medical procedure within a given geographic area. Some examples may include the following:

• Presbyterian Health Plan’s fee schedule for the services provided.
• Fees that a professional provider usually charges for a given service.
• Fees that fall within the range of usual charges for a given service filed by most professional providers in the same locality who have similar training and experience.
• Fees that are usual and customary or that could not be considered excessive in a particular case because of unusual circumstances.

You have the right to make a complaint if you have concerns or problems about your coverage or care. Appeals and grievances are the two different types of complaints you can make.

• An appeal is the type of complaint you make when you want us to reconsider a decision we have made about what services are covered for you or what we will pay.
• A grievance is the type of complaint you make if you have any other type of problem with Presbyterian or one of our plan providers.
• You can submit a complaint by calling Presbyterian Customer Service Center or by submitting a complaint online.

Subrogation is a process in which a health insurance company can seek recovery from a third party legally responsible for a medical accident or injury after the health insurance has processed the services.

Health insurance companies can subrogate if they have paid your medical costs and you later recover amounts for the medical costs in a lawsuit. If Presbyterian Health Plan has paid for medical services related to the lawsuit, you will receive documents that will detail the amount your insurance company has paid for your injury claim and an explanation of the insurance company’s subrogation rights to collect.

When you receive medical treatment from an in-network provider, the provider will submit the claim to Presbyterian Health Plan for payment. Depending upon the service, you may be responsible for a copayment at the time of the visit. After Presbyterian Health Plan has processed the claim, you may owe the provider any coinsurance and/or deductible amounts according to your benefit plan. Refer to your benefit plan for a summary of copays, coinsurance and deductible amounts.

When you visit an out-of-network provider, the provider may require payment in full at the time of service and require that you send the claim to Presbyterian Health Plan. Please be aware that non-urgent or non-emergent services received from an out-of-network provider may require prior authorization from Presbyterian Health Plan. To submit a claim to Presbyterian Health Plan, please complete a Member Medical and Pharmacy Claim Form and submit the information to:

Refer to your plan documents for a full description. Some deductible plans cover 100% after the deductible is met including copays and coinsurance. Other plans still require the copay and coinsurance after the deductible is met. Also, some benefits could have maximums or limits. This means that if you have met your maximum lifetime benefits, you will be responsible for any remaining payments.

It may be that you haven’t met your deductibles for both plans. If this is the case, you may still owe your cost-sharing amounts (deductible, copayment, coinsurance).

If you are a member of an Employer Group Plan, there are a few things you can expect from Presbyterian after enrollment:

• You will receive your ID card, Group Subscriber Agreement and Summary of Benefits prior to your group’s plan effective date or approximately 30 days after you have completed the enrollment process with your employer.
• If your employer has enrolled for the Presbyterian Welcome On-Boarding Program, you will receive a series of welcome emails that will help you make the most of your health plan benefits and instructions to take advantage of the tools and resources available to you.
• Please inform us if you have additional healthcare coverage. By sharing this information we can better coordinate your benefits. You can do this by contacting Presbyterian Customer Service Center and request a Coordination of Benefits form.
• Transition of Care: Please let us know if you were previously covered by another insurance company and you have a pre-existing medical condition or pharmacy drug prescription. We will assist you in the transition to ensure that your benefits are handled properly.

If you are currently seeing a primary care provider (PCP) or specialist through another network, under some circumstances you may continue to do so. In these instances, you must let us know so we can help you temporarily continue certain treatments with providers outside of the network following enrollment. This is called transition of care.

Transition of care coverage may include upcoming surgeries, prenatal care, specialist visits, home healthcare, durable medical equipment and other types of services. You will need to fill out the Transition of Care Services Request form online or request one from the Presbyterian Customer Service Center.

Presbyterian Health Plan’s Health Services department will review your request to determine if it meets the criteria for transition of care coverage. Upon approval, you will be given a prior authorization for any eligible coverage. You might find it helpful to watch this video on prior authorizations.

If you currently receive case management or disease management services through another plan, you may also be able to enroll in Presbyterian’s case management and disease management programs.

• Form to Transition Care Services

Services that are pre-approved through transition of care by Presbyterian Health Services are covered at your plan’s in-network benefit level through the specified coverage period. There may be some services – such as outpatient surgery, lab work, radiology and durable medical equipment – that will require a transition to another facility. We will provide you a listing of those facilities in the Presbyterian network. For pregnancies, the coverage period may be longer. Please indicate on the Transition of Care form if you are pregnant.