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PPO Plan Member Frequently Asked Questions

Q. May I use any provider I choose under this plan?

A. Yes, you can choose to see any provider. However, precertification or prior authorization is required for some services as indicated in the Certificate and your Schedule of Benefits. Use of out-of-network providers for some services may not be a covered benefit or may be subject to deductibles, co-insurance or copayments. The level of benefit is determined by whether you use an in-network provider or an out-of-network provider.

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Q. How do I obtain precertification?

A. You may obtain precertification by contacting our Managed Care division at (800) 279-1301 or (608) 836-1400.

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Q. May I use in-network providers for some services and out-of-network providers for others?

A. Yes, however, your coverage may change as you change providers, as explained in your Schedule of Benefits. Prior authorization and precertification requirements may apply.

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Q. Will I incur any liability if I fail to obtain precertification when it is required?

A. Yes, you will be responsible for 50 percent of covered services if you do not obtain precertification. These amounts apply toward satisfaction of the maximum out-of-pocket expense. Maximum allowable fees may also apply if an out-of-network provider is used.

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Q. Whose responsibility is it to provide the medical information that Dean Health Plan requires under the precertification provisions?

A. It is the member's responsibility to make sure this information is relayed to us. Any fees incurred due to release of this information are also the member's responsibility.

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Q. When should precertification take place?

A. You must contact our Managed Care division at (800) 279-1301 for precertification of a planned, elective admission at least 10 business days prior to the planned admission date. This includes inpatient and outpatient admissions to hospitals, alcohol and drug abuse residential centers, skilled nursing facilities and licensed ambulatory surgery centers. Be prepared to give information regarding your member number and the nature of your need for care.

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Q. What about emergency admissions?

A. In the case of an urgent/emergency admission, you must notify our Managed Care division by the next business day for precertification approval. Managed Care can be reached at (800) 279-1301.

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Q. What should be done in cases of maternity?

A. Our Managed Care division must be notified in advance of your expected date of delivery for precertification of your maternity facility stay. In addition, when you are admitted we must be notified by the next business day regardless of whether delivery of your baby has taken place or not (e.g., pre-term labor). Managed Care can be reached at (800) 279-1301.

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Q. Who is responsible for any amount charged by an out-of-network provider that exceeds the maximum allowable fee?

A. Payments for charges submitted by out-of-network providers will be limited to the maximum allowable fee as defined in the Glossary section of your Member Certificate and any amount charged that exceed this limitation will be the member's responsibility.

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Q. If Dean Health Plan is closed and prior authorization is not possible, when must I notify the Managed Care division of my outpatient emergency?

A. In most cases you will not need to notify our Managed Care division of emergency outpatient care in advance. If you have an emergency procedure or admission that requires approval, you are required to contact us the next business day. Follow-up treatment after emergency care is also subject to the prior authorization requirements. Managed Care can be reached at (800) 279-1301.

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Q. Do I need to decide at the time of enrollment whether I use in-network providers or can I decide this at a later date?

A. No, you are not required to choose a network provider at the time of enrollment. It is your option at any time to choose in-network or out-of-network providers. Note: there is a higher cost to you for out-of-network providers.

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Q. What are my responsibilities if my in-network provider refers me to an out-of-network provider? Do I need to obtain a written referral?

A. This plan does not require referrals. If you see an out-of-network provider, the out-of-network provider benefits will apply. However, certain types of care need prior authorization or precertification from our Managed Care division. Please refer to your Schedule of Benefits.

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Q. Which deductible or copayment applies if an in-network provider refers me to an out-of-network provider?

A. The deductible or copayment/co-insurance that you pay is determined by the participation of the provider you see. Please refer to your Schedule of Benefits.

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Q. Who is a qualified dependent?

A. A qualified dependent may be:

  1. a legally married spouse
  2. a biological child from birth, adopted child, child placed for adoption, or stepchild to the maximum dependent age limitation selected by your employer
  3. a legal ward residing with you in a parent-child relationship who is dependent on you for at least 50 percent of support and maintenance
  4. a grandchild, until the eligible parent dependent child reaches age 18

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Q. Do copayments apply separately to the in-network and out-of-network maximum out-of-pocket expenses?

A. Yes. Copayments apply to in-network maximum out-of-pocket expenses separately.

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Q. How will I know whether or not the deductible and/or maximum out-of-pocket expense on my plan has been met?

A. If there is any liability on your part, you will receive an Explanation of Benefits (EOB) which will explain what has been paid by Dean Health Plan and what amount of the claim you are responsible for. The EOB will also indicate how much of the deductible and maximum out-of-pocket expense has been satisfied.

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Q. How can I find out about maximum allowable fees?

A. The EOB, which you will receive for every claim submitted from an out-of-network provider, will explain the maximum allowable fee and your financial responsibility. You can find out the maximum allowable fee for a particular procedure prior to having a service performed. Contact your provider to request the procedure code and amount the provider will charge. Then, contact our Customer Care Center at (800) 279-1301 and request information about maximum allowable fees. Within five days of your request, we will advise you whether the service is fully covered and if it is subject to any plan provisions (deductibles, co-insurance, copayments or pre-existing conditions).

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Q. If I receive a denial for certain services, what can I do?

A. You have the right to appeal Dean Health Plan's decision. Please see the Complaint, Appeal, and Grievance Procedure section of your Member Certificate for additional information.

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Q. If I lose coverage through my employer due to termination of employment, divorce, dependent reaching limiting age or for other reasons, how can I continue to receive coverage?

A. You may meet the eligibility guidelines of the State or Federal (COBRA) laws for group continuation. Please contact your employer and they will be able to assist you to determine if you are eligible. You may also contact the Customer Care Center at (800) 279-1301 for assistance.

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