Q&A: PPO Plan

Yes, you can choose to see any provider. However, prior authorization or precertification 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.

You can obtain prior authorization by contacting our Customer Care Center at (800) 279-1301 or (608) 836-1400.

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

Yes, a penalty may be applied if you fail to obtain a prior authorization when it is required.

It is your responsibility to make sure prior authorization is completed, and you may need to coordinate with the provider. Any fees incurred due to release of this information are also the member's responsibility.

To ensure there is time to complete the prior authorization of your services, contact our Customer Care Center at (800) 279-1301 as soon as you are aware of a planned service. 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 like your member number and the nature of your need for care.

In the case of an urgent/emergency admission, you must notify our Customer Care Center by the next business day for prior authorization approval. You can reach the Customer Care Center at (800) 279-1301.

Our Customer Care Center must be notified when you are admitted for your maternity stay by the next business day following your admission regardless of whether the delivery of your baby has taken place or not (e.g., pre-term labor). You can reach the Customer Care Center at (800) 279-1301.

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. Any amount charged that exceeds this limitation is the member's responsibility.

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.

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.

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 from our Managed Care division. Please refer to your Schedule of Benefits.

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.

A qualified dependent may be:

  • a legally married spouse
  • a biological child from birth, adopted child, child placed for adoption, or stepchild to the maximum dependent age limitation selected by your employer
  • 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
  • a grandchild, until the eligible parent dependent child reaches age 18

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

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.

The EOB, which you receive for every claim submitted from an out-of-network provider, explains 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).

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.

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