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HEALTHY
Futures
PIEDMONT COMMUNITY HEALTH PLAN
Customer Service
our abandonment rates, response and wait times.
Our goal is to continue to move in this positive direction!
HEALTHY
futures
Summer Is Here!
Questions?
Piedmont Community Health Plan is
here to help. You can reach Customer
Service at (434) 947-4463 or toll-free
1-800-400-PCHP, Monday through Friday between the hours of 8:30 a.m. and
5:00 p.m. We are located at 2316 Atherholt Road in Lynchburg, VA.
ommendations will reduce the harmful effects of the sun’s ultraviolet rays:
•
S
ummer is upon us. The summer
weather sets the tone for cookouts,
pool activities, ball games, and simply
being outside to enjoy the warm climate.
As comforting as the nice sunny days can
be, it can also bring danger to your health.
According to the Skin Cancer Foundation,
skin cancer occurs when “Unrepaired
DNA damage to skin cells (most often
caused by ultraviolet radiation from sunshine or tanning beds) triggers mutations,
or genetic defects, that lead the skin cells
to multiply rapidly and form malignant tumors.” In fact, one in five Americans will
actually develop skin cancer during his
or her lifetime. Taking the necessary precautions can provide a more enjoyable
summer experience and help prevent sun
damage to your skin. The following rec-
Sunscreen. Everyone needs sunscreen. It is important to look for a
sunscreen that protects against UVA
and UVB rays, a SPF of 30 or higher,
and is water resistent. Apply generously to areas that are exposed to
the sun. This includes the face, ears,
arms, and hands. Lip balms with a
SPF of 30 and higher are available
for your lips.
Sunscreen has a shelf life of three
years; however, not all of them provide an expiration date. For bottles
that do not include the expiration
date, simply write the date of purchase on the bottle to help keep track
of its shelf life. Usually after this date
the sunscreen cannot contain it’s
original strength.
•
Wear protective clothing. Cover
your body with long sleeved shirts,
pants, and wide brimmed hats.
-Continued on page 3
NCQA Interim Accreditation
Phone:434-947-4463
800-400-PCHP (7247)
Fax:434-947-3670
Website:www.pchp.net
Piedmont Community Health Plan
2316 Atherholt Road
Lynchburg, VA 24501
SUMMER
2016
Customer Service is, and always has been,
a top priority at
Piedmont Community Health
Plan. We pride
ourselves
on
taking good care
of our customers and meeting
their needs. In addition to increased enrollment,
we have recently experienced higher call volumes
and other technical issues in our Customer Service area which has affected our accessibility and
response times. We are working on solutions that
we expect will enable us to return to our historical good response performance very soon. We
have upgraded the technical infrastructure and
additional representatives are being hired. Our
new trainees appreciate your patience and understanding during the initial phase of their training.
We are already experiencing improved results in
The
National
Committee for
Quality Assurance
(NCQA)
has
awarded
Piedmont Community HealthCare with the Interim Health Plan Accreditation. This recognition is achieved
by organizations who meet specific criteria for consumer protection and quality
improvement. We are honored to receive
this accreditation for the following product lines: Commercial - PPO, Medicare PPO, and Marketplace - PPO
The NCQA Health Plan Accreditation has
established rigorous standards for determining the quality of clinical performance
and consumer experience. NCQA is the
most widely-recognized accreditation
program in the United States.
National Committee for Quality
Assurance. (n.d.). Health Plan
Accreditation. Retrieved from
http://www.ncqa.org/Programs/
Accreditation/HealthPlanHP.aspx
SUMMER 2016
Inside This Issue
Summer Is Here!..........................1
NCQA Interim Accreditation..........1
New CEO.....................................1
Exchange News...........................2
Deductible or Co-pay?..................2
Women’s Health & Cancer
Rights...........................................2
Updates from Medical
Management ...............................3
Customer Service.........................4
New PCHP CEO
Mr. Richard Tugman
has been named the
new CEO of Piedmont
Community
Health Plan, effective
April 12, 2016.
In this role, Mr. Tugman will provide leadership for a team dedicated to ensuring members the access
to medical care that represents the highest standards for quality and efficiency.
His most recent role as Centra’s Vice
President of Corporate Compliance &
Retail Strategy provided the opportunity
for him to ensure a well-developed and
responsibly managed Compliance Program.
Prior to Centra, Richard was the Vice
President and General Counsel at Fleet
Laboratories. He oversaw regulatory affairs, product liability, Fleet’s intellectual
property portfolio, HR and Medical Affairs.
-Continued on page 2
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Deductibe or Co-pay?
D
to provide certain services as an approved facility with the state, in which
case, the deductible or coinsurance
would apply for those specific services. It can be confusing because you
are under the same roof of the physician practice and yet part of the building or some of the services provided
apply under a facility.
eductible versus co-pay is an area
of health insurance that can seem
confusing. Basically, claims are billed
from the provider of the service to the
insurance company as either a charge
in a doctor’s office visit, which would
take a co-pay and or coinsurance as
applicable to your benefits or as a
facility charge at any licensed facility
such as a hospital, where the charge
would go toward your deductible.
Once licensed as a facility, these providers must submit their charges as
such, with ANY insurance carrier they
are billing. In turn, your benefit is paid
under the facility benefit, which generally requires deductible and coinsurance instead of an office visit co-pay.
Benefit plans vary also. Some plans
require deductible and coinsurance
even in a doctor’s office for certain
services.
Also, there are different kinds of licensed facilities where services can
be received outside of a hospital.
Here are a few to be aware of so you
will know what to expect when you
have services performed in a facility.
Just remember that wherever you are
receiving medical services, always
ask how your visit or procedure will be
billed. Simply ask, “Will this be going
under my co-pay or will this be applied
towards my deductible?” It’s always
better to know upfront instead of when
you receive your Explanation of Benefits, or a bill in the mail. If you ever
have questions on any bill please call
Piedmont Customer Service at 434947-4463. We are here to help!
The hospital is the obvious one, but
also the emergency room bills as a facility. An outpatient surgery center or
any place that does diagnostic testing
like MRIs and PET scans and other
imaging is usually a facility. There are
also doctor offices that are licensed
Women’s Health & Cancer Rights
In 1999, a federal law, the Women’s Health and Cancer Rights Act of 1998, became
effective for group health plans. This law requires health plans such as Piedmont to
provide coverage for mastectomies and for reconstructive surgery and prosthesis following mastectomies. As required under the law, Piedmont is providing this notice to
inform you about the Act.
The law mandates that participants who receive benefits for a covered mastectomy on or after the law’s effective date for their plan - and who elect breast reconstruction
in connection with the mastectomy, will also be covered for the following treatment(s):
•
•
•
Reconstruction of the breast on which the mastectomy was performed.
Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
Prosthesis and treatment of physical complications at all stages of the mastectomy including lymphedemas.
This coverage will be provided in consultation with the patient and the patient’s attending physician and will be subject to the same annual deductible, coinsurance, and/or
co-payment provisions otherwise applicable under the plan.
Updates from PCHP Medical Management Department
New PCHP CEO
-Continued from page 1
Access To PCHP Medical Management
Piedmont Community Health Plan offers case management programs that facilitate the provision of high quality care, appropriate benefit utilization and support for our members. Case Management is available to address any utilization/case management
issue(s) between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday. If you have a specific question about your case
or other health/treatment issue, please call (434) 947-4463 or (800) 400-PCHP and follow the prompts to speak with a Medical
Management representative. If you call after normal business hours, you can leave a secure voicemail. A Medical Management
representative will return your call the next business day.
Mr. Tugman’s background includes experience in global legal, risk management,
compliance and governance issues. He
holds a Bachelor of Law Degree from
University of Kent at Canterbury, England
and a Master in Law from Tulane University.
Utilization Management
Utilization Management (UM) is defined as a set of techniques to manage healthcare costs by assisting patient care decisionmaking through case-by-case assessments of the appropriateness of care “prior to” its provision. Utilization Management decision-making is based only on the appropriateness of the care and service(s) requested and existence of coverage. Piedmont
does not reward or compensate practitioners or other individuals conducting utilization review for denials of coverage or service.
Financial incentives for utilization management decision makers do not encourage decisions that result in underutilitzation. Appropriate care is provided within professionally recognized standards of practice that is not withheld or delayed for any reason
including a financial gain and/or incentive to the practitioners and/or others.
Exchange News
Piedmont’s Individual Marketplace offers the option of paying plan premiums
online. This process grants the member
the ability to access the site at his or her
convenience and allows for a much faster
payment method than mailing a check. To
make a payment visit www.pchp.net and
follow these steps:
• Select the Individual Marketplace tab
• Click on the “Payment Instructions”
tab from the side menu
• Scroll to the bottom where you will
find a section titled “Paying your
monthly premium.” There you will find
“To pay your premium online, Click
Here”. It will redirect you to a member
log-in portal.
• Click on the word “Member Portal
Login” where it will then redirect you
to login page.
In addition, Piedmont does not make decisions regarding the hiring, promotion, or termination of its medical directors or utilization management staff based upon the likelihood (perceived or real) that the individual will support or tend to support the denial
of benefits.
Evaluation of New Technology
To keep pace with technological changes in the healthcare field and to ensure that members have access to safe, effective,
and medically necessary care, Piedmont has a process to evaluate and review new medical technology as it applies to our
members.
To determine the need to approve a new technology, licensed clinical professionals will review approved criteria as part of the
decision-making process. In addition, Piedmont may review appropriate information from scientific literature and regulatory
bodies. Piedmont’s clinical staff, in consultation with practitioners with expertise in the related field, may develop clinical criteria
used to authorize or deny use of such technology.
Summer Is Here!
-Continued from page 1
You will have the opportunity to create a
user name and password, if you have not
set this up before. Once you are logged
in, you will have access to a variety of online member services. For example, you
can pay your premium online, view benefits, check eligibility, check claims, or order an ID card.
If you are brand new to Piedmont, please
keep in mind that your policy and benefits
will not take effect on your effective date
of coverage until Piedmont receives your
initial premium payment. You will receive
an invoice in the mail requesting payment
within 5-10 days after enrolling in our
plan. The initial payment can be paid using cash, check, or money order. Credit or
debit card may be used; however, you will
have to call the office to process this initial
transaction.
Check Us Out
at www.pchp.net or on...
Page 3
If you want to create a suntanned look, you
can apply a sunless tanning lotion. It provides a darker look but without the danger.
Tanning lotions can usually be found at
your local convenience store in the same
aisle with moisturizing lotions and/or near
the sunscreen.
•
Shade. The sun’s rays are the strongest between 10 a.m. and 2 p.m. Harmful effects can even occur on cloudy
or hazy days. Seeking shade during
these hours will significantly protect
you from the harmful rays of the sun.
•
Avoid tanning beds and sun lamps.
Tanning beds and sun lamps emit UVA
and usually UVB rays that contribute to
skin cancer.
•
Be aware of reflective surfaces. Water, snow, and even sand will reflect the
sun’s rays. The reflection will increase
your chance of getting a sunburn.
Adjusting your daily routine to include
these useful recommendations will allow
you to enjoy the beautiful weather and help
maintain healthy skin. The sun’s UV rays
shouldn’t discourage you from getting outside and enjoying the best of what mother
nature has to offer.
Skin Cancer Foundation. (n.d.). What is
Skin Cancer? Retrieved from http://
www.skincancer.org/skin-cancerinformation
American Academy of Dermatology.
(n.d.). Sunscreen FAQs. Retrieved
from https://www.aad.org/media/stats/
prevention-and-care/sunscreen-faqs
Know Your Rights
When a claim is reviewed
for payment, personal information about the services you received is often
furnished to Piedmont by
healthcare professionals or
institutions. This information is necessary so we can
administer your benefits.
However, you do have the
right to review and correct
any such information. If you
would like a more detailed
description of your rights
please call Piedmont’s Customer Service at (434) 9474463 or 1-800-400-PCHP