PPO Plan type responsibilities
Your patients may have one of these CIGNA HealthCare PPO plans:
- PPO—members have both in-network and out-of-network coverage. You're responsible for filing the claim form; you're also responsible for obtaining precertification for all in-network services that require it.
- EPO—members have in-network benefits only, except in emergency and urgent care situations. You're responsible for obtaining precertification for all in-network services that require it.
These payment responsibilities are listed on the member's ID card.
Please contact us for more information about CIGNA HealthCare HMO and Network plans, or about how to become a CIGNA HealthCare provider.
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PPO Plans Offers Members Flexibility
The member has selected a CIGNA HealthCare PCP to be his overall care coordinator, and makes an appointment for a wellness exam. His physician orders some lab tests and suggests he see a specialist about some problems he has with his stomach. He makes an appointment with a specialist in the CIGNA PPO network.
| Cost Example |
|
|
| PCP office visit/exam fee |
$85 |
|
| Your Copayment |
$20 |
|
| Lab tests (done in PCP's office) |
No cost to you |
|
| Specialist visit/fee |
$150 |
|
| Your Copayment |
$45 |
|
|
|
|
If the member chooses to see a physician who is not in the PPO network, he will have to pay the full amount until he meets his deductible, then pay a predetermined coinsurance amount.
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FAQ
Do I have to choose a PCP?
You are not required to choose a primary care physician. However, a primary care physician gives you and your dependents a valuable resource and a personal health advocate.
What if my doctor is on your list?
That means your doctor does not participate in the Open Access Plus/CareLink network. To receive your maximum benefit, you should select a doctor from the list of participating Open Access Plus/CareLink providers. Participating providers must meet standards to become a part of the network. You can continue seeing your current doctor, even if he or she is not a participating provider. However, in that case, you will pay higher out-of-pocket costs, and your care will be covered at the out-of-network benefits level.
Do I need a referral to see a specialist?
Though you may want your personal doctor's advice and assistance in arranging care with a participating specialist, you do not need a referral to see a participating specialist. If you choose to see an out-of-network specialist, the health care services you receive will be covered at the out-of-network benefits level.
What is the difference between in-network coverage and out-of-network coverage?
When you visit an Open Access Plus/CareLink participating doctor, you will have lower out-of-pocket costs. That's because these providers have agreed to charge lower fees, and your plan's benefits cover a larger share of the charges.
With out-of-network benefits, you can see any doctor you wish and still be covered for treatment of any illness or injury. Keep in mind, however, that your out-of-pocket costs will be higher if you choose a doctor who doesn't participate in the Open Access Plus/CareLink network.
Do I have to choose between in-network and out-of-network coverage now?
No. Each time you seek medical care, you can choose your doctor — either in- or out-of-network.
How do I find participating doctors?
Search for participating Open Access Plus/CareLink doctors in the Provider Directory or visit the online directory at www.cigna.com and select Open Access Plus/CareLink.
What if I go to an out-of-network physician who sends me to a network hospital? Will I pay in-network or out-of-network charges for my hospitalization?
CIGNA HealthCare will cover authorized medical services provided by a Open Access Plus/CareLink participating hospital at your in-network benefits level — whether you were sent there by an in- or out-of-network doctor.
What is utilization review?
Utilization review is a process that helps determine if the services you receive are a covered benefit. CIGNA HealthCare performs utilization review, including hospital pre-admission certification, continued stay review and case management. Requests for non-emergency hospital stays other than maternity stays must be approved in advance.
Precertification is not required for a maternity stay of 48 hours for vaginal deliveries, or 96 hours for caesarean sections. Depending on your benefits plan, you may be eligible for additional benefits. Any maternity hospital stay beyond the initial 48 or 96 hours must be approved. Please call the toll-free number on your CIGNA HealthCare ID card for details.
Who is responsible for obtaining precertification?
Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis.
If your doctor participates in the Open Access Plus/ CareLink network, he or she will arrange for precertification. If you use an out-of-network doctor, you are responsible for making the arrangements.
What if my doctor keeps me in the hospital longer than my precertification allows?
CIGNA HealthCare will contact your hospital the day before you are scheduled to be discharged. If your physician has extended your stay, then the additional days will be reviewed for coverage. CIGNA HealthCare will continue to review your hospital stay for coverage until you are discharged.
If you remain in the hospital for services that are not covered, your out-of-pocket costs may be higher.
Can my current doctor be added to your network?
If your current doctor meets our credentialing standards and is interested in becoming a participating provider, he or she can call our Provider Relations Department to get more information on joining the Open Access Plus/CareLink network.
What if my doctor is on the list, but his/her office is shown as "accepting current patients only"? Can I still choose my doctor?
If you are an existing patient of a participating doctor, you may select him or her to provide your care.
Am I covered for emergency care?
Whenever there is an emergency, seek medical help immediately. An emergency is an accident or sudden illness that a person with average knowledge of medical science believes needs to be treated right away or it could result in serious medical complications or permanent disability.
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