MEMBER UPDATE | Second Quarter 2014
Coordination of Benefits (COB)
Coordinating benefits with other insurance carriers is one way we avoid duplicating (and overpaying) payments to health care providers and one
way to lower health care costs. If an overpayment occurs, providers are required to
research which health insurance carrier is owed money back, then send the money back to the
carrier that overpaid. The insurance carriers are required to adjust previously paid claims.
The process of coordinating benefits is commonly referred to as “COB”.
We will be sending you a request for updated medical insurance information every year. Please
complete the form. If you don’t have any other insurance, simply check the box that says “No”,
sign and date the form and return it to us. If you have other insurance, complete the form with
the other insurance information. Each member of your family will receive their own form.
It’s important that PHP receive updated COB information for each family member.
It’s also important you return the form promptly. If you delay in sending the form back to us,
you may receive another form from us, or you may get a phone call asking about your other
insurance information. Claims will be denied if you do not respond to our requests for your
other insurance information.
You can complete the form anytime if your other insurance information changes. The form is
available on our website, www.phpmichigan.com in the Member Reference Desk. You can mail,
fax or email the completed COB form to us. If you have any questions about the other insurance
information we have on file for you or your family members, or questions about COB in general,
contact Customer Service at 517.364.8456 or 800.203.9519.
PRIOR AUTHORIZATION REQUIREMENTS:
Genetic Testing
G
enetic testing is special blood testing that is ordered by your physician and helps determine how likely you are to get certain conditions or diseases. Genetic testing is becoming
more common as we learn more about the accuracy of the test results and the value of
the information obtained. Usually, your physician will also order genetic counseling in addition to
the genetic test. Genetic counseling helps prepare you for your test results.
Your PHP Benefit Plan covers many genetic tests when criteria is met and prior authorization is
obtained. Your physician should contact our Medical Resource Management Department (MRM)
before you have the test. We will review the request against criteria and notify both you and your
physician of the decision. You may be charged for the test if the authorization is not approved prior
to having the test.
If you have questions or concerns about genetic testing, talk to your physician. If you have question
or concerns about benefit decisions, requirements, or if you do not understand why a health service
was denied or the benefit reduced, you can reach staff in MRM during normal business hours
(Monday-Friday, 8 am -5 pm) 517.364.8560 or toll free at 1.866.203.0618. www.phpmichigan.com
PHP Privacy Statement
PHP Insurance Company respects your privacy and has always followed strict procedures
to maintain confidentiality of your health
information.
Types of information we collect
We collect a variety of personal information
to administer your health coverage. Information is provided by members, employers, insurance agents, physicians and other
providers through enrollment forms, surveys,
correspondence, medical claims and other
needed data exchanges. We have access to
personal addresses, social security numbers,
dependent information, medical claims and
other insurance information. We limit the
collection of personal information to what
is needed to meet regulatory requirements,
conduct business and provide quality service.
How we protect your information
We protect your information through strict
physical, electronic and procedural security
standards. We limit access to persons who
need to know and train those individuals on
the importance of safeguarding information
and compliance with procedures and applicable law.
Disclosure of personal information
We only share information as permitted or required by law. Sharing of information may be
necessary to conduct business with affiliates
and non-affiliated entities such as our attorneys, accountants and auditors, a member’s
authorized representative, health care providers, third party administrators, insurance
agents or brokers, other insurers, consumer
reporting agencies, law enforcement and
regulatory authorities. We may also share information with contracted companies for the
purposes of marketing or disease management programs. We do not disclose personal
information to any other third parties without
a member’s request or authorization.
A copy of the PHP Notice of Privacy Practices may
be downloaded from the PHP website, www.phpmichigan.com, or you may contact Customer
Service at 517.364.8456 or 800.203.9519 to
obtain a copy by mail.
Summary Financial
Information
(as of December 31, 2013)
Enrollment: 10,945
Balance Sheet Data
(in thousands)
Total Current Assets.................. $14,858
Total Non-Current Assets................... $–
Total Assets............................... $14,858
Total Current Liabilities............... $6,504
Total Non-Current Liabilities.............. $–
Unrestricted Net Assets............... $8,354
Total Liabilities & Net Assets..... $14,858
Statement of Operations Data
(in thousands)
Total Revenue.............................$41,211
Health Care Delivery Cost..........$37,437
Administration............................ $5,101
Net Operating Income.............. $(1,327)
Net Investment Income.................... $(9)
Net Income Before Taxes.......... $(1,336)
Income Tax Expense...................... $(311)
Net Income................................ $(1,025)
A full report is on file with the State of
Michigan Department of Financial &
Insurance Regulation and is available
for public inspection. The information
shown above is derived from the audited
financial statements, which are also on file
with the State of Michigan Department
of Financial and Insurance Regulation.
www.phpmichigan.com
The Women’s Health and Cancer Rights Act of 1998
The Women’s Health and Cancer Rights Act (WHCRA) requires coverage for reconstructive breast surgery and related services following mastectomy. Medical/surgical coverage
includes:
•Reconstructive surgery of the breast on which a mastectomy has been performed.
•Surgery and reconstruction of the other breast to produce a symmetrical appearance.
•Prosthesis and treatment of physical complications through all stages of a mastectomy, including swelling associated with the removal of lymph nodes.
•Treatment determined in consultation with the attending physician and patient.
Refer to your certificate of coverage for levels of coverage and required copayments or coinsurance. All terms and conditions of your health benefit plan will apply to this coverage.
Asking the right questions can help avoid unnecessary
out of pocket expenses
Who can I contact for answers to my questions
about benefit decisions?
It’s important to verify the participation status of a
provider before you have an appointment. Usually
you can find out if the provider is a PHP network
provider or a provider who is contracted with your
primary network, as identified on your PHP ID
card, when you make your first call to the office.
Getting the correct information can be determined
by how you ask this very important question.
If you have questions or concerns about benefit
decisions, or if you do not understand why
a health service was denied or the benefit
reduced, contact our clinical staff in Medical
Resource Management (MRM.)
You may call a new physician’s office and ask the
receptionist if the doctor “accepts” your insurance.
To some offices, “accepting” a certain insurance
plan does not mean that the physician you plan to
see is a contracted, Network provider. The office
staff may interpret your question to mean “Will
you bill my insurance directly or do I have to pay
for the appointment myself?” Many offices will
bill insurance companies on your behalf regardless
of the type of insurance you have and the contracting status of the physician you plan to see.
Rephrase your question and instead of using the
word accept, ask if the physician you plan to see is
a contracted, Network physician with PHP Insurance Company or with your primary network, as
identified on your PHP ID card. Make sure to ask
about a specific physician, because not all physicians within a practice are contracted, especially if
the physician is new to the practice. If the physician is not contracted, contact your PCP for names
of other providers in the same specialty.
You can also contact PHP or GlobalCare to verify
the participation status of the physician you plan
to to see or use our interactive provider directory,
located on our website, www.phpmichigan.com.
CALL OR VISIT
You may call us during normal business hours,
Monday through Friday, 8:00 a.m. to 5:00 p.m.,
at 517.364.8560 or toll free at 866.203.0618.
After business hours you may call MRM at
517.364.8500 or toll free at 800.832.9186. You may also visit us in person. Our office is
located at 1400 East Michigan Ave, Lansing,
Michigan 48912.
TTY/TDD SERVICE
You can use the TTY/TDD service if you are
deaf, hard of hearing, or have trouble speaking. You must have a device with a keyboard
called a Teletypewriter or a Telecommunications
Device for the Deaf. If you have one of these
special devices, call 800.649.3777 to reach the
Relay Center who will help you call the MRM
Department.
TRANSLATION TO ENGLISH
If English is not your native language, you can
still call the MRM Department. Simply state
what language you speak and the MRM coordinator or nurse will have an interpreter translate
your questions and explain the answers to you.
We will help you understand the information
or you can have someone you know help you.
If you want to designate someone to help you,
let us know. PHP will work with other family
members or caregivers.
Help us identify billing errors
Looking for a network physician?
An Explanation of Benefits (EOB) is a helpful
tool you can use to identify billing errors. You
will receive an EOB for every health service
you receive where you have a copay, coinsurance or part of the charge is applied to your
deductible. You will also receive an EOB if the
health service is not a covered benefit. An
EOB represents the bill sent to PHP Insurance
Company by your doctor or other health care
provider. This bill is also called a claim.
If you live in Michigan but outside of
PHP’s core service area…
We are obligated by law to send appeal rights
with all EOBs. You do not need to file an
appeal if you agree with the charges and your
copay, coinsurance and deductible amounts.
If you have a question on why you are being
assessed a copay, coinsurance or deductible
amount, or why something was not covered,
call Customer Service before you fill out the
appeal form. Often, we can explain why you
are being assessed this amount and filing an
appeal will not be necessary.
An EOB contains the following valuable
information:
•The date of your appointment or service.
•An itemized list of the procedures performed
and the charge for each procedure.
•The name of the doctor or other health care
provider that provided the service.
•The amount PHP Insurance Company was
billed for the service.
•The amount PHP Insurance Company paid for
the service.
•Your copay, coinsurance or deductible amount.
If you spot a charge for a procedure you did
not have, please call Customer Service. We will
investigate the situation with the provider.
PHP has partnered with GlobalCare, a network
management firm, to enhance our doctor and
hospital coverage in Michigan when outside of
the PHP service area. If you live in Michigan, but
outside of PHP’s core service area, you may access
network providers across the entire state through
the Cofinity PPO network. Closer to mid-Michigan, you have access to the PHP network and to
the PCN network, in the Jackson area.
If you live outside of Michigan…
Through our relationship with GlobalCare, our
members who live outside of Michigan enjoy
access to providers across the country. Check
your ID card, which will identify your provider
network. Outside of Michigan, your provider
network will either be Private Healthcare Systems
(“PHCS”), or another local network and PHCS.
If you need help finding a network provider, just
call GlobalCare at 866-807-6193 for personal
assistance.
If you are traveling…
GlobalCare will secure access to providers in the
remaining 49 states through network relationships with Multiplan and PHCS. Logos for these
two networks are on your ID cards. Their addition
makes it easier for providers to recognize you are
part of a health plan affiliated with Multiplan and
PHCS when you travel.
You can check your provider’s network status
on our website. Please visit www.phpmichigan.
com to look up network providers in your area
or call GlobalCare at 866-807-6193 for personal
assistance.
Go online for important benefit information!
Visit the Member Reference Desk, an online resource for your Certificate of Coverage, commonly used forms and other important benefit information. Visit our website at www.phpmichigan.com and click on the “Member
Reference Desk” link on the home page. You will need your PHP identification
number to access the Member Reference Desk.
Your Appeal/Grievance Rights
You have the ability to appeal our decisions about issues impacting your coverage, including benefit
and eligibility determinations. We call your request to review a determination a “grievance”. PHP
follows State of Michigan and U.S. Department of Labor regulations with respect to our Appeal/
Grievance Procedure.
If you want to file an appeal/grievance, please follow these steps:
•Contact the Customer Service Department at 517.364.8456 or 800.203.9519. One of our
Customer Service Specialists will be happy to help you and will try to answer your questions
or solve your problem informally.
•If our informal attempts to resolve your request do not meet your expectations, you have
the right to request a formal review. These requests must be communicated to us in writing.
For your convenience, an Appeal/Grievance Form is available on our website, from Customer
Service or you can submit your appeal/grievance in an informal letter. (The form is not
necessary but helps us obtain the minimum information needed to review your request.) You can also send us a secure e-mail message through our Web site.
•You may submit any additional documentation to support your request at this time.
•You may appoint someone else, including a physician, to act on your behalf at any point
in the appeal/grievance process.
STEP 1:
You will be notified in writing that we have received your written appeal/grievance. We will
review the information provided and we may obtain additional information, if necessary. We will notify you in writing of our initial decision on your request within 20 calendar days from the date we received your request.
STEP 2:
If you are not satisfied with our initial decision, you can request a grievance hearing. You must
request a grievance hearing within 60-calendar days from the date of our Step 1 decision letter. The grievance hearing process gives you an opportunity to speak to a committee about your
request. You can submit additional information with your grievance hearing request and you can
participate in your grievance hearing either in person or via teleconference. We will notify you in
writing of the committee’s final decision.
EXTERNAL REVIEW
If you are not satisfied with our final decision, you have the right to seek External Review through the State of Michigan, Department of Insurance and Financial Services (DIFS). You must submit
your request to DIFS within 60 days of receipt of our Step 2 decision letter. If necessary, we will
include a form and information on how to file request for an External Review through DIFS with
our final letter.
Expedited Appeal
The above appeal/grievance procedures do not apply if you have a dispute with PHP over an
upcoming health service that needs to be treated as an urgent situation. In this case, the usual
time frame for an appeal would seriously jeopardize your life, health or ability to regain maximum
function. You and/or your physician must explain the nature of your condition and why you require
an expedited review. PHP will inform both you and your physician of its decision within 72 hours of
when PHP is notified of the urgent situation. If our determination is provided verbally, we will put it
in writing no later than two business days after notification.
For urgent situations, you may ask for review by the Insurance Commissioner at the same time that
you go through the PHP appeal/grievance process. For information about the review of an urgent
situation by the Insurance Commissioner, you should contact:
Department of Insurance and Financial Services
PO Box 30220, Lansing MI 48909-7720
Phone: 877.999.6442
www.michigan.gov/difs
www.phpmichigan.com
Lansing MI 48909-7877
PO Box 30377
PHP Administration
Correspondence can be directed to:
Call 517.364.8509
To contact the Board of Directors
*Denotes Enrollee Director
Dennis Swan
Kenneth Rudman, M.D.
Deborah Muchmore*
Patrick McPharlin
David Kaufman, D.O.
Thomas Hofman, Ph.D.*
Timothy Hodge, D.O.
MaryLee Davis, Ph.D. .
Kathleen Conklin*
Judith Cardenas, Ph.D.
James Butler, III
Mark Brett
Diana Rodriguez Algra*
2014 Physicians Health Plan
Board of Directors
P.O. Box 30377
Lansing, MI 48909-7877
PAID
LANSING, MI
PERMIT NO. 28
PRST STD
US POSTAGE