During an emergency situation, where pre-certification cannot be performed, is there any risk of not being covered by health insurance?

No. Emergencies do not require pre-certification.

How do I know what procedures need to be pre-certified?

A list of procedures requiring pre-certification are on the back of your ID card, along with the number for your provider to call to pre-certify them.

What procedures/services require pre-certification?

All inpatient and outpatient procedures or surgeries performed in a facility (as defined above) require pre-certification and authorization. In addition, there are other services listed in the utilization review section of your plan document that will require pre-certification and authorization. These include but are not limited to: inpatient and outpatient behavioral health and chemical dependency; home healthcare and hospice care; physical, occupational and speech therapy; complex imagining (MRI, PET, CAT scan, etc.); and chemotherapy and radiation therapy. A copy of your plan document can be found on the mylucenthealth.com portal. Your physician should contact the pre-certification number listed on your ID card to have the procedure pre-certified. Narus Health will check for medical necessity and advise the provider if the requested service is authorized by the plan. PLEASE NOTE: Narus Health recommends the provider start the pre-certification process 5-7 days prior to the scheduled service date. Providers should call Lucent Health to confirm your eligibility and benefits at 877-214-2129.

What do I do if I go to a physician or ancillary service provider and they will not accept my insurance?

When possible, it is best to verify that your physician or ancillary service provider is in the network prior to your scheduled appointment. If there are any complications with the physician or ancillary service provider accepting your insurance when you arrive for your appointment, contact Narus Health at the number on your ID card right away. Narus Health will verify your coverage and benefits and explain that all physicians are paid at the same benefit level as PHCS providers on your plan.

My physician is not currently in the PHCS network. Will the medical plan continue to provide coverage for visits to my physician?

Yes. This is an open access plan and all covered services for physician and ancillary providers, regardless of PHCS participation, can be submitted for coverage under the medical plan. Your costshare (applicable deductible, out-of-pocket and copay amounts) will not be affected by the provider’s participation in PHCS.

What is a value-based payment (VBP) plan?

Most health plans rely on a preferred provider organization (PPO) network. In this model, the PPO negotiates a contract with a facility and any claims incurred are paid based on that contract. In the VBP plan, facility claims are repriced based on a percentage of Medicare payment. This results in a lowered cost of care for everyone involved. For procedures performed in a facility, the process begins during pre-certification. The plan requires you to gain preapproval for these procedures by calling the utilization review company at the number listed on your ID card. At this time, the plan may provide an estimated payment amount to the facility. Once the procedure has been performed, the plan pays based on that estimate as well as any other charges incurred during the procedure, just like a normal plan. Because these claims are paid outside of a network contract, there is a chance the provider will dispute the payment amount and potentially balance bill you. In these cases, you should contact Narus Health at the number on your ID card. Narus Health will work with the Patient Advocacy Center (PAC) to educate the provider on the plan payment and negotiate, if necessary, to settle the balance bill. You may be required to sign some documents allowing the PAC to advocate for you while it is resolving the bill. The PAC will keep you informed on the status of the efforts until an agreement is reached. Please note, the PAC process takes on average 60 days to complete.

Are my financial obligations capped at my out-of-pocket maximum? I will not be liable for the full “balance bill”?

That is correct. If you receive a bill from your provider that shows your responsibility is more than your explanation of benefits reflects, call Narus to alert them that you received a balance bill.

What providers can I see? What facilities can I go to for treatment?

For physician and ancillary services, your plan utilizes a physician and ancillary only network called PHCS. However, your plan is open access for facilities, physicians and ancillary providers, which allows you to choose any service provider and facility. Your cost-share (applicable deductible, out-of-pocket and copay amounts) will not be affected by the provider’s lack of participation in PHCS. Further, you can choose to receive services at any hospital, skilled nursing facility, ambulatory surgery center or behavioral health facility where inpatient or outpatient services are provided.

How do I find a PHCS physician or ancillary provider?

PHCS: Contact PHCS to find a physician and confirm they are in the PHCS network. Online at www.multiplan.com/lucentphcs By phone at 877-559-7427

What should I do if my current physician is not in the PHCS network, but I would like to continue seeing them?

If it is verified that your physician is not currently in the PHCS physician and ancillary only network, you may request PHCS to contract with your physician about becoming a participating provider by submitting a nomination, as follows: PHCS: A. Go to https://www.multiplan.com/nominate/ B. Complete the online form to nominate your provider.

FAQs Archive - Page 4 of 4

During an emergency situation, where pre-certification cannot be performed, is there any risk of not being covered by health insurance?
No. Emergencies do not require pre-certification.

Continue reading
How do I know what procedures need to be pre-certified?
A list of procedures requiring pre-certification are on the back of your ID card, along with the number for your provider […]

Continue reading
What procedures/services require pre-certification?
All inpatient and outpatient procedures or surgeries performed in a facility (as defined above) require pre-certification and authorization. In addition, there […]

Continue reading
What do I do if I go to a physician or ancillary service provider and they will not accept my insurance?
When possible, it is best to verify that your physician or ancillary service provider is in the network prior to your […]

Continue reading
My physician is not currently in the PHCS network. Will the medical plan continue to provide coverage for visits to my physician?
Yes. This is an open access plan and all covered services for physician and ancillary providers, regardless of PHCS participation, can […]

Continue reading
What is a value-based payment (VBP) plan?
Most health plans rely on a preferred provider organization (PPO) network. In this model, the PPO negotiates a contract with a […]

Continue reading
Are my financial obligations capped at my out-of-pocket maximum? I will not be liable for the full “balance bill”?
That is correct. If you receive a bill from your provider that shows your responsibility is more than your explanation of benefits reflects, […]

Continue reading
What providers can I see? What facilities can I go to for treatment?
For physician and ancillary services, your plan utilizes a physician and ancillary only network called PHCS. However, your plan is open access for […]

Continue reading
How do I find a PHCS physician or ancillary provider?
PHCS: Contact PHCS to find a physician and confirm they are in the PHCS network. Online at www.multiplan.com/lucentphcs By phone at 877-559-7427

Continue reading
What should I do if my current physician is not in the PHCS network, but I would like to continue seeing them?
If it is verified that your physician is not currently in the PHCS physician and ancillary only network, you may request PHCS to […]

Continue reading

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