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.
What providers can I see? What facilities can I go to for treatment?Jill Lackey2022-05-01T18:41:07+00:00
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?Jill Lackey2022-05-01T18:41:39+00:00
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:
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.
None of my doctors are in the network. So you are saying they will all join if we call Narus Health?Jill Lackey2022-05-01T19:24:06+00:00
If you receive a bill from a service provider that represents an amount owed by you that is greater than the amount represented on your Lucent Health Explanation of Benefits (EOB) as your “patient responsibility” for the same services, then you have received a balance bill.
What should I do if I receive a balance bill?Jill Lackey2022-05-01T19:25:08+00:00
Contact Narus Health at the number on your ID card. Narus Health will work with the plan to resolve the balance bill.
A. Facility – If the balance bill is from a facility, 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 documents allowing the PAC to represent you while it resolves the bill. The PAC will keep you informed on the status until an agreement is reached. Please note, the PAC process will take an average of 60 days to complete.
B. Physician and Ancillary – If the balance bill is from a physician or ancillary provider, Narus Health will educate the provider on the plan payment and work to settle the bill. Narus Health will keep you informed on the status during this process.
Please remember that you will be responsible for any amount represented as “patient responsibility” on the Lucent Health EOB. Make sure to pay your patient responsibility to the provider or contact the provider to set up a payment plan.
How do I know what amount I’m supposed to pay to my providers and the facilities?Jill Lackey2022-05-01T19:03:03+00:00
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.
How do I know what procedures need to be pre-certified?Jill Lackey2022-05-01T19:06:32+00:00
Contact Narus Health at the number on your ID card. Narus Health will collect your name, member ID number, physician’s name and contact information, type of procedure requested, and expected date of procedure. Your provider will be notified when the pre-certification is complete and authorization has been granted.
What should I do if my physician has pre-certified my procedure but the facility where the procedure is scheduled says it will not accept my insurance and I will have to pay upfront if I do not want to cancel the procedure?Jill Lackey2022-05-01T19:09:47+00:00
Contact Narus Health at the number on your ID card. Narus Health will collect your name, member ID number, facility name and contact information, physician’s name and contact information, type of procedure, and date of procedure. Narus Health will coordinate with the plan on your behalf and let it know that the facility is not accepting the insurance. The plan will contact the facility and, if needed, begin pre-service negotiations. Narus Health will keep you informed on the status of the procedure.
Explanation of Benefits (EOB)
It seems that you stated that if I go to my physician and pay my copay, then the provider will send everything to Lucent Health and then I will receive my explanation of benefits (EOB). Is that right? Will I find out my EOB after the service has already been provided?Jill Lackey2022-05-01T19:11:25+00:00
Yes, as it is with every health insurance plan. The provider may give you an itemized statement the day you see them, or they may mail you an itemized statement. The claim must be submitted and processed to generate an EOB.
Why did I receive three different explanations of benefits (EOB) for one procedure or surgery?Jill Lackey2022-05-01T19:12:09+00:00
If you have a procedure that requires multiple physician and ancillary doctors to be in attendance to provide services, each provider will bill separately for their services. It is not uncommon for one procedure to result in claims from the facility, a surgeon (sometimes multiple surgeons), anesthesiologist (sometimes multiple anesthesiologists), and a laboratory. The plan will process and pay your claims as they are received, and you will receive an EOB for each claim submitted for payment.
What services are covered as “Preventive Care” and covered 100% of the allowable amount by the plan?Jill Lackey2022-05-01T19:28:56+00:00
The preventive care benefits covered under the plan include:
A. Services with an A or B rating recommended by the United States Preventive Services Task Force (USPSTF).
B. Immunizations for routine use in children, adolescents and adults who have a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.
C. With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
D. With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of USPSTF).
E. All Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.
F. Routine physical exam and associated diagnostic tests and immunization.
G. Prostate specific antigen tests.
H. Mammograms are limited to one baseline mammogram beginning at age 35 and then annually for ages 40–74.
I. Shingles vaccination beginning at age 50.
For a complete listing on the services covered as “Preventive Care” by the plan, please refer to the Summary Plan Description (SPD).
Do I need to call Narus Concierge to discuss my mammogram?Jill Lackey2022-05-01T19:13:53+00:00
You may call Narus Concierge if you have questions about scheduling your mammogram. Your plan covers mammograms as follows: Age-appropriate preventive mammograms are covered at 100% with no cost share by the member. The plan (your employer) pays for them. Diagnostic mammograms are subject to the member’s deductible or coinsurance. In either case, it is a good idea to call Narus Health to help locate an imaging center that is in-network or that does not issue a balance bill.
What is the procedure with prescription drugs?Jill Lackey2022-05-01T19:14:39+00:00
No. You do not need to call anyone to get your prescriptions. You need to call Narus Health only if you have questions about your medications. For medical benefits, you need to call Narus Health only if you have questions, if you would like help finding a provider or understanding your benefits or EOBs, or if you receive a balance bill.
Is there a way to communicate with the Narus Concierge team other than phone?Jill Lackey2022-05-01T19:17:16+00:00