Plan Benefit FAQs

What is Protected Health Information (PHI)? And can I call the Customer Care Center on behalf of one of my dependents?

PHI is any information about health status, health care or payment for health care that can be linked to a specific individual. Even though you are still providing their health insurance, in the eyes of privacy law, your 18-year-old is now an adult and, as such, he or she has to provide permission for you to see their private health information. If you plan on making calls to the Prevea360 Customer Care Center about your dependent over the age of 18 while they are away at college, your adult dependent must complete an Authorization for Disclosure form. By completing this form you will be able to speak with a Prevea360 Customer Care Specialist about claims or billing statements related to services your child over the age of 18 has received.

If I have not yet received my ID card, what do I need to do to keep my appointment?

If you have an upcoming appointment but have not received an ID card, you can print a temporary card using your member profile. If necessary, a Customer Care Specialist will contact the clinic or provider’s office to verify coverage.

How do I obtain a reprint of my ID card?

Call the Customer Care Center or log into your member profile to request a copy. Via your member profile you can also print a copy of your ID card from your home computer.

What is a copay?

A copayment is a fixed dollar amount that must be paid each time services are received. Note that even if a copay has been collected at your appointment, it may not be reflected in your Explanation of Benefits (EOB). Your EOB will not reflect any payment you have already paid to a provider.

What is coinsurance?

Coinsurance is generally a fixed percent of a covered health care cost for which you have financial responsibility. For example, if you received a bill from Prevea360 for $100 and your plan includes a 20 percent coinsurance you are responsible to pay $20. Your EOB will not reflect any payment you have already paid to a provider.

How are deductibles accumulated?

The deductible is the amount that you must pay before your insurance begins to cover expenses. For families, each member must meet the “single” amount to begin receiving benefits, but once the “family” amount has been met, no more deductibles will be collected for any family member.

I am a PPO or POS member and currently seeing a provider who is not in my assigned network. Will you pay for this service?

Your best and most affordable coverage comes from receiving care from providers in your assigned network. Members can choose to see in-network providers for some services and out-of-network providers for others. Covered benefits, deductibles, co-insurance and copayment costs are calculated for each person, for each visit or treatment, depending on the provider chosen for that service. If you see an out-of-network provider, services are paid according to the out-of-network benefit level. Payment for charges submitted by out-of-network providers are limited to the maximum allowable fee (after the deductible and coinsurance are applied). Payments for charges submitted by out-of-network providers will be limited to the maximum allowable fee as defined in your Member Certificate and Schedule of Benefits and the amount(s) charged that exceed this limitation will be the member’s responsibility. Please note that some services do require prior authorization. Contact Prevea360 before seeing an out-of-network provider to check if prior authorization is required.

What if I require urgent or emergency care when outside my assigned network?

You or your qualified dependents (including dependents living outside the coverage area) are covered for urgent or emergency services outside of your assigned network. For follow-up care and any covered elective procedure please check your Member Certificate. It is important that you and your dependents are established with a PCP and have their ID card before traveling or living away from home.

What do I need to do if I am a Network member and need to see a specialist?

If your specialist is an in-network provider, no prior authorization is needed. If the specialist is an out-of-network provider, you must have an approved prior authorization in order for your services to be covered. Please contact your PCP to request that a prior authorization be submitted to Utilization Management.