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You have questions . . . we have answers.  Browse through some of our most commonly asked questions or contact us for additional information.

What is your payer ID number for claims submission?

PHP's ID number is 12399.  Please see the HIPAA section of our site for further information regarding electronic claim submission.

How long does the credentialing process take?

The time to credential varies based upon the completeness of the application and the return of all required documentation to our Credentialing Coordinator.

How do I obtain reimbursement for a specific CPT code?

PHP provides each contracted provider fee schedule information for their top 10 codes.  To obtain the reimbursement simply provide PHP with a list of CPT codes along with the billed.  Your request can either be faxed to Provider Services at (260) 432-0493, or emailed to us at providerservices@phpni.com.

Do you utilize CAQH for provider credentialing?

PHP does utilize CAQH for credentialing.  The Provider Participation Form gave you the option to use the CAQH database or submit a paper application.

Do you contract for ancillary healthcare providers such as Nurse Practitioners, Nurses, Physicians Assistants, and Certified Registered Nurse Anesthetists?

PHP does contract for ancillary healthcare providers if they are employed by a provider practice currently contracted with PHP.  We do not contract directly with these providers.

Why is it important to understand my pharmacy benefit?

Getting the most out of your healthcare insurance coverage is important. If you understand your pharmacy benefit and how it works, you can use it to save money on the cost of your prescriptions and thus maximize your benefit.

It is important to work with your doctor on how best to maintain your good health and how to successfully manage any existing health conditions you may have.

When medicines are needed to treat a health condition, be sure that you understand how to get the most effective drug treatment while controlling the cost of your prescriptions.

Why is a member requested to split tablets?

Many prescription drugs actually cost the same amount, regardless of the strength, meaning that a 20mg pill of a certain medication could cost the exact same amount as a 40mg pill.  Specific medications are appropriate for tablet splitting and can offer immediate out-of-pocket savings.

Why does the health plan have a formulary?

Health plans use formularies to manage the cost of pharmaceutical healthcare.  Formulary guidelines and protocols are used to encourage doctors to prescribe according to a predetermined therapeutic strategy developed by local health professionals.

Where can I get drug formulary information?

Our Customer Service Department can provide drug formulary information, or you may check for formulary information listed at www.phpni.com.  All PHP participating doctors and pharmacies automatically receive a copy of the drug formulary each year along with updates throughout the year.

Where can I find additional information on prescription drug benefits?

For more information, and for a complete listing of the pharmacy providers in our service area, call PHP Customer Service or visit the pharmacy and network sections of our website at www.phpni.com.

What is Step Therapy?

Some medications require the use of an alternate prescription drug within a specified number of days before they can be covered.  This alternate prescription process is referred to as Step Therapy.

What is a Prior Authorization?

Certain medications have a status of Prior Authorization Required (PAR).  If your doctor wants to prescribe a PAR drug, he or she will submit a request for approval before the drug can be dispensed as a covered benefit.  If your pharmacist receives notification that a drug you were prescribed requires prior authorization, ask your pharmacist to contact us.

What is a generic drug? Is it safe to take instead of the brand-name drug?

A generic drug is a copy of the original drug that is no longer protected by a US patent.  It is typically a drug that has been available for more than 20 years.  Generic drug manufacturers are allowed to produce these medications after the patent for the original brand has expired.  Generic drugs are less expensive than brand-name drugs since generic manufacturers have not had to invest in the research and development of the drug when it was brought to market.  Substituting a generic drug for a brand-name drug usually has no adverse effect.

What is a formulary?

A formulary is a list of prescription drugs that PHP encourages our doctors to prescribe when appropriate.  This formulary was developed with the help of area doctors and pharmacists.  The formulary is updated quarterly and may change at any time.

What is a five-tiered copayment pharmacy benefit and how does it work?

A five-tiered copayment benefit means there are five possible copayment levels. A member’s copayment is based on the prescription drug being purchased. For example, the first tier represents a preferred generic drug that has the lowest copayment.

  • TIER 1 Preferred Generic:  Covered drugs that are no longer protected by a drug company patent allowing other drug companies to manufacture equivalent versions of the same drug at a reduced cost. 
  • TIER 2 Non-Preferred Generic:  Similar to Tier 1 covered drugs, but available with a higher copayment. 
  • TIER 3 Brand Formulary:  A list of brand-name drugs that PHP participating network doctors are encouraged to prescribe, when appropriate, for treatment of a medical condition. 
  • TIER 4 Brand Non-Formulary:  Covered drugs that are not included in the formulary listing. You may obtain non- formulary brand-name drugs with a higher pharmacy copayment. 
  • TIER 5 Specialty Drugs:  Specialty drugs are generally injectable, high-cost medications, which you may obtain through our specialty pharmacy, unless administered by a PHP network provider. 

Example: Please note that copayment amounts will vary depending on your benefit plan.

If a doctor prescribes ............................Copayment is

TIER 1 ..................................................$ 4

TIER 2 ..................................................$ 10

TIER 3 ..................................................$ 30

TIER 4 ..................................................$ 60

TIER 5..................................................$250

* If you or your doctor want a brand name drug when there is a generic drug available, you will have to pay more than the formulary or non-formulary brand copayment.

What if the member wants the brand-name drug in place of a generic drug?

If the drug is covered by PHP, we will allow the brand.  However, the member will be responsible for the cost difference between the brand and the generic in addition to the normal copay.  This is known as an ancillary charge.

What if the member is traveling and needs medication?

If traveling and a medical emergency occurs that requires prescription medication, simply take the prescription to one of our 40,000 participating pharmacies across the nation, including Walgreens, CVS, and Wal-mart Pharmacy locations.  If unable to locate a participating pharmacy, take the prescription to a local pharmacy.  The member may be required to pay the full price of the prescription.  When they return home, submit the pharmacy claim for reimbursement.  In order for PHP to consider the claim, they must include the receipt, name of the medication, quantity, diagnosis, date of service, and member name and number.

What if a doctor wants to prescribe a non-formulary medication?

A doctor may prescribe a prescription drug that is not on the PHP formulary.  The member has the option to receive the non-formulary medication at a higher pharmacy copayment or to ask the doctor for a formulary medication.

What are specialty drugs?

Specialty drugs are generally injectable, high-cost medications that have special handling requirements or require special training before use.  These types of medications may be obtained through our specialty pharmacy, unless administered by a participating PHP network provider.  Depending on the benefit plan, specialty drugs may have a different copayment and out-of-pocket expense than the three-tier pharmacy structure.

Is prescription mail order service available?

Yes.  We use Express Scripts, a mail service pharmacy program that provides fast and convenient delivery of maintenance medications directly to your home for up to a 90-day supply.  You pay only the copayments as determined by your benefit plan, just as if you were receiving a prescription filled at the local pharmacy.  Express Scripts can be reached at (800) 557-3952 or visit the Express Scripts Pharmacy Web site at www.express-scripts.com.  To obtain a mail order form or for information about the mail order program, please contact our Customer Service Department.

How can a copayment be lowered to save money on drug prescriptions?

By asking the doctor if a generic drug is available for the treatment of a medical condition, the member may become eligible to take advantage of savings by lowering the pharmacy copayment.  To allow for generic drug substitution, ask your doctor to use the signature line located on the right side of the prescription.

Can I use a copay assistance program or discount card?

Members are required to pay the applicable cost sharing, which includes the Deductible, Copays or Coinsurance as shown on the Schedule of Benefits. The requirement to pay the applicable cost sharing (Deductible, Copays or Coinsurance) cannot be waived by a provider, a pharmacy or anyone else under any “fee forgiveness,” “no out-of-pocket,” “discount program,” “coupon program” or similar arrangement. If a provider, a pharmacy or anyone else waives the required cost sharing (Deductible, Copays, Coinsurance) for a particular claim, the claim shall be denied and the member will be responsible for payment of the entire claim. The claim may be reconsidered if the member provides satisfactory proof that he or she paid the applicable cost sharing (Deductible, Copays or Coinsurance) required.

Are there limits on the amount that can be dispensed?

Some medications may be subject to quantity level limits based on the manufacturer's packaging insert.  These Quantity Limits are designated in the Drug Formulary by (QL) next to the medication name.  The purpose of these maximum quantity limits is to ensure the proper billing of products.  It also encourages the use of therapeutically indicated medication regimens.

Are pharmacy services available on the Web?

At our Web site, www.phpni.com, members can refill mail order prescriptions and check for possible drug interactions.

Practitioner Site & Recordkeeping Standards

PHP site and medical recordkeeping standards are based on several sources including OSHA regulations, AMA documentation recommendations, and NCQA requirements.

GENERAL

  1. There will be adequate parking space, lighting, seating, and appearance of the office site.
  2. There will be handicap accessible parking places, entrances, and rest rooms at each site.
  3. All compressed gas tanks will be in-wall lines, wall mounted, or in approved containers for safety.
  4. Fire extinguishers will be accessible, filled, and dated. Inspection date will be within one year of date of review.
  5. There will be at least two exits. Exits will be easily identified and hallways will be unobstructed.

EXAMINATION ROOMS

  1. Syringes and needles will not be easily accessible to patients.
  2. Disposable patient care equipment (ear speculums, vaginal speculums, etc.) is recommended, but not required.
  3. Reusable equipment will be decontaminated appropriately.
  4. Sterile equipment package dates will not be expired.
  5. Paper towel wall dispensers will be in use.
  6. Soap dispensers will be in use.
  7. Trash containers will have liners.

APPOINTMENTS/TRIAGE

  1. Access parameters:
    • Emergent-Immediate access.
    • Urgent-Within 72 hours.
    • Routine-Within 4 weeks.
    • Health Maintenance Exam (routine physical)-Within 4 months.
    • After Hours-Physician contact within 1 hour.
  2. Telephone and/or walk-in triage procedures will ensure that members receive appropriate, medically sound advice, as well as recognition of, and intervention in urgent/emergent situations.
  3. Outside of business hours urgent care procedure/expectations will be easily accessible to members to ensure twenty-four hour a day health care access.

MEDICATIONS

  1. Medications will be stored in a way that deters access by patients.
  2. Medication dates will be monitored for expiration dates on a regular schedule.
  3. Medications will be labeled with name of medication, strength, and expiration date visible.
  4. Refrigerated medications will be stored in a separate refrigerator. (No food or specimens.)
  5. Medication refrigerator will have a thermometer inside, demonstrating a temperature of between 2-8oC or 36-46oF.
  6. There will be evidence that the temperature is monitored on a routine basis, and corrective actions taken if the temperature is found to be outside of above range.
  7. Narcotics and other Schedule II medications will be stored in a double locked manner with a record of usage.
  8. Members will receive accurate prescription medications with appropriate information.

INFECTION CONTROL

  1. Regulated waste is disposed of in closed, leak resistant, red color-coded or biohazard labeled containers.
  2. Contaminated laundry is bagged and labeled as such. If laundry is wet, container will be leak resistant.
  3. Sharps containers are puncture resistant, leak resistant, closeable, and placed as near as feasible to the area of use.
  4. Hand washing facilities are available, accessible, and in use.
  5. If an autoclave is used, efficacy is ensured by:
    • Live spore counts performed at least annually, and heat/steam sensitive tape test at least monthly, or
    • Live spore counts at least monthly.
    • There will be documentation of above.
  6. Contaminated surfaces and equipment are decontaminated with an appropriate disinfectant whenever contaminated, and at the end of every work shift.
  7. Universal Precautions are observed to prevent contact with blood or other potentially infectious materials.
  8. Personal protective equipment is available and in use.

INSPECTIONS/ CERTIFICATION

  1. All practitioner labs that perform examination of any human specimens for the purpose of assessing health, or diagnosing, preventing, or treating any disease or impairment will have a CLIA certificate to ensure that all federal requirements have been met.
  2. If x-rays are performed on site, a current certificate will be displayed.

MEDICAL RECORDKEEPING

  1. There will be a written policy for the maintenance of medical records, which addresses confidentiality.
  2. Medical records will be stored in a safe, accessible manner that maintains member confidentiality.
  3. Medical records will be maintained in a consistent, organized manner, which facilitates continuity of care and accessibility of information. (Includes problem list, consistent allergy or nkda notation, immunization records for children and adolescents, physician notation of diagnostic tests, consultation reports, etc.)
  4. Each patient's medical record is separate. (May be separate within family records.)
  5. Inactive records will be maintained in a safe and retrievable place for at least 7 years.
PHP Medical Record Standards

PHP medical record standards are based on AMA documentation recommendations and NCQA requirements.

  1. Each page of the medical record will include patient identification, either by name or ID number.
  2. Personal biographical information will be included on each patient's medical record.
  3. All entries in the medical record will contain author identification.
  4. All entries will be dated.
  5. The medical record will be legible.
  6. Significant illnesses and medical conditions will be indicated and readily identifiable on a problem list or flow sheet.
  7. Medication allergies and other adverse reactions will be noted prominently in the medical record. If there are no known allergies, this should also be noted in the record.
  8. Past medical history will be easily identifiable. (Includes serious accidents, operations, and illnesses. Includes menstrual and pregnancy history of adolescent and adult females. For children and adolescents, relates to prenatal care, birth, operations, and childhood illnesses.)
    • Family history will be available.
    • Social history will include age appropriate assessment. (Includes assessment of alcohol, tobacco, and other substance use/abuse by patients 14 years or older.)
  9. Each encounter note will include a reason for encounter (chief complaint), history and physical exam (subjective/objective assessment), a clinical impression or diagnosis, a plan regarding treatment and/or further evaluation, and when indicated, follow-up care.
    • Unresolved problems from previous visits will be addressed in subsequent visits.
    • Medication administration/injection will be recorded, including drug name, dosage, and route.
  10. Lab, x-rays, and other studies will be ordered appropriately and documented in the encounter note. The reason for the above studies will be documented or easily implied.
  11. Consultants will be utilized appropriately.
    • When consultation has been requested, there will be a report or notation from the consultant in the medical record.
  12. Consultation, lab, and imaging reports filed in the chart will be initialed by the primary care physician to signify review, or a notation is made in the medical record acknowledging review of specific diagnostic test results.
    • Reports presented electronically or by other methods have some representation of physician review. Consultation, abnormal lab and imaging study results have an explicit notation in the record of follow-up plans.
  13. Medical records of children and adolescents 0-16 years old will contain documentation of each immunization. When immunizations are not up to date, documentation will indicate reason or plan.
    • Immunization documentation will contain record of serum, manufacturer, lot number, date, and site of administration for immunizations provided after 1995.
    • If immunizations are obtained elsewhere, the medical record should note this, and that immunizations are up to date.
Payer ID Information for Clearinghouses

PHP accepts electronic claims from all clearinghouses, as well as HIPAA-compliant files from providers.  Our payer ID number is 12399.*

If you have any questions or issues regarding electronic claim submission, please contact PHP Customer Service at (260) 432-6690, ext. 11; toll-free at 1-800-982-6257, ext. 11; or custsvc@phpni.com.

* Our payer ID number is also 12399 for electronic remittance advice (835).

Outpatient Procedures Review

Below is a listing of our outpatient procedure reviews for a select group of procedure codes. These procedure codes require pre-certification from your office and will be subject to a review process by our Medical Management staff to ensure quality and appropriateness of care to our membership receiving medical services.

Please review the list below of the selected procedures that will be affected by this review process.

Procedure: Nasal fracture and/or dislocation

Codes: 21310, 21315, 21320, 21325, 21330, 21335, 21336, 21337

Here are additional procedure codes that will be subjected to outpatient procedure reviews. These codes have been considered as non-covered services as they are performed for cosmetic reasons

Procedure: Rhinoplasty

Codes: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462

For further information regarding outpatient procedure reviews, please contact PHP Medical Management at (260) 432-6690, ext. 12.

Off-Plan referrals

A referral to a non-participating specialty doctor may be obtained if a uniquely specialized procedure is medically necessary and not performed by any participating doctors.  This process must be requested by the participating doctor and approved by PHP, in writing, prior to receiving the services.  It is the member's responsibility to notify us of the initial appointment date, or a change to the date they were given by the physician.

If the visit results in a recommendation for further treatment such as therapy, durable medical equipment, additional testing or surgery, the member must notify us prior to receiving these services.  The non-participating specialty doctor you were referred to should send claims associated with the visit to:

PHP
PO Box 2359
Fort Wayne, IN 46801-2359

After the visit, the non-participating specialty doctor should send the treatment plan summary to:

PHP Medical Management
1700 Magnavox Way, Suite 201
Fort Wayne, IN 46804

or by fax to (260) 436-4809.

Download a list of services requiring prior authorization.

Modifier – 63

Procedure Performed on Infants less than 4 kg: Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician or other qualified health care professional work commonly associated with these patients. This circumstance may be reported by adding modifier 63 to the procedure number. Note: Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20005-69990 code series. Modifier 63 should not be appended to any CPT codes listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.

“CPT 2019 American Medical Association. All Rights Reserved”

Modifier - 76

Modifier 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service.

“CPT 2019 American Medical Association. All Rights Reserved”

How to Use Modifiers Correctly

Modifier

Description

Documentation Required

Applicable Procedure Codes

Applicable to E&M Codes

-22

Unusual services

X

X  

-24

Unrelated E&M service by the same physician during a post-op period

X   X

-25

Significant, separately identifiable E&M service by the same physician on same day of a procedure or other service (E/M codes only)

X

 

X

-50

Bilateral procedure

 

X

 

-51

Multiple procedure

  X  

-52

Reduced services

 

X

 

-57

Decision for surgery

    X

-59

Distinct procedural service

X

X  

-77

Repeat procedure/another physician

 

X

 

-78

Return to OR/related procedure

 

X

 

-79

Unrelated procedure post-op

 

X

 

-80

Assistant surgeon

 

X

 

-91

Repeat clinical diagnostic laboratory test

 

X

 

JW

Discarded drug not administered

X

X  
HCPCS -LT and -RT Modifiers

PHP accepts and encourages the use of the modifiers -LT and -RT when performing the same x-ray bilaterally. Appropriate use of these modifiers can expedite claim processing and eliminate duplicate service denials. 

LT - Left side (used to identify procedures performed on the left side of the body)

RT - Right side (used to identify procedures performed on the right side of the body)

Unlisted Procedure or Service

When submitting claims for services, drugs or procedures performed by physicians that do not have a specific CPT or HCPCS code, do not select a code that merely approximates the services provided. If no such procedure, drug or service codes exists, report the service using the appropriate unlisted procedure, drug or service code. 

The following will help to expedite the processing of claims with unlisted codes.

  • When submitting an unlisted code for drugs, include Name of Drug, NDC number and dosage given.
  • When submitting an unlisted code for surgical procedures, include description of procedure and operative and pathology notes.
  • When submitting an unlisted code for radiology service, include description and radiology report.
  • When submitting an unlisted code for equipment or other services, include description.
Removal of Skin Tags

11200 - Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

11201 - Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure)

Generally, removal of skin tabs are considered cosmetic and is not covered.  If documentation is submitted and it supports medical necessity then payment will be considered.

“CPT 2019 American Medical Association. All Rights Reserved”

RAST Testing (86003)

It is PHP’s intent to cover RAST testing when percutaneous testing cannot be done for inhalant or food allergy due to any of the following reasons:

  • Presence of severe dermatographism, ichthyosis or generalized eczema, which would make reading of skin tests impossible.
  • Patient who needs allergy testing cannot safely discontinue antihistamines long enough to perform skin tests.
  • Uncooperative patient, such as small children or those with mental handicap.
  • Patients with high risk of anaphylaxis from skin testing.
  • Direct skin testing is inconclusive. 

Coverage of RAST testing is limited to 25 specific tests in any three month period. PHP intends to deny coverage when the above criteria has not been met. 

Before ordering RAST testing, please reference the Medical Policy Allergy Testing which is available online at www.phpni.com

“CPT only © 2009 American Medical Association. All Rights Reserved”

Preventive Visits with Problem Oriented E/M Services

If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-orientated E/M service than the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem orientated E/M service should not be reported.

“CPT 2019 American Medical Association. All Rights Reserved”

New and Established Patient

A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

“CPT 2019 American Medical Association. All Rights Reserved”

Maternity Services

Please notify PHP of all multiple births and high risk pregnancies by calling PHP Medical Management at (260) 432-6690 or (800) 982-6257, ext. 12. The following guidelines are associated with maternity claims submission:

GLOBAL MATERNITY SERVICES

Services provided in uncomplicated maternity cases include antepartum care, delivery and postpartum care.

Antepartum Care includes: 

  • physical examinations
  • initial and subsequent history 
  • blood pressure
  • recording weight
  • routine chemical urinalysis
  • fetal heart tones
  • monthly visits up to 28 weeks gestation
  • biweekly visits up to 36 weeks gestation
  • weekly visits until delivery

Delivery Services include:

  • hospital admission
  • admission history and physical examination
  • induction of labor
  • management of uncomplicated labor
  • vaginal delivery (with or without episiotomy or forceps)
  • cesarean delivery 

Postpartum Care includes:

hospital and office visits following vaginal or cesarean delivery

GLOBAL CODES 

  • 59400 Routine obstetric care including antepartum care vaginal delivery and postpartum care. 
  • 59510 Routine obstetric care including antepartum care, cesarean delivery and postpartum care. 
  • 59610 Routine obstetric care including antepartum care, vaginal delivery and postpartum care after a previous cesarean delivery. (VBAC) 
  • 59618 Routine obstetric care including antepartum care, cesarean and postpartum care following attempted vaginal delivery after previous cesarean delivery. 

ANTEPARTUM CARE ONLY

Antepartum or prenatal care includes the initial and subsequent histories, physical examinations, recording of weight, blood pressures, fetal heart tones, and routine chemical urinalysis. 

  • 59425 Antepartum care only, 4 - 6 visits.
  • 59426 Antepartum care only, 7 or more visits. 

Although these codes are intended to indicate a certain number of visits, PHP is set up to pay these codes per occurrence. When you submit claims for Antepartum care alone, be sure to indicate the specific date and number of times you saw the patient. This will assure proper payment.

BREAK-OUT SERVICES 

Break-out of services is required when a PHP member: 

  1. has more than one physician or physician group providing services during her maternity care 
  2. change in insurance plan during her pregnancy 
  3. has miscarried 

The individual codes listed below are to be used when breaking out services: 

  • E/M code 1-3 OB visits CPT 59425 4-6 OB visits* 
  • CPT 59426 7 or more OB visits* 
  • CPT 59410 Uncomplicated vaginal delivery including postpartum care 
  • CPT 59515 Uncomplicated cesarean delivery including postpartum care 
  • CPT 59409 Vaginal delivery only 
  • CPT 59514 Cesarean delivery only 
  • CPT 59430 Post Partum care only * 

The individual office visit codes require a range of service dates. The number of units in box F should indicate the number of visits in the range and include all services as outlined in "Antepartum Care.” 

MULTIPLE BIRTH DELIVERIES 

Contact PHP for assistance in correct coding of multiple birth deliveries

What happens if you don’t provide an SBC to employees?

An employer can be assessed a fine of $1,000 per affected individual where the employer or carrier willfully fails to provide an SBC. Other penalties can include a $100 per day, per affected person fine issued by the Department of Labor or Health and Human Services. PHP will be held harmless from all costs associated if you fail to distribute the SBCs as required by the ACA or other applicable regulations. If PHP is fined in relation to the employer’s failure to abide by any SBC legal requirements, the employer will be liable to reimburse PHP for any resulting fines and/or penalties. 

What happens if there is a benefit change?

Before PHP can revise any SBCs for distribution by the employer group, the group must provide adequate advanced notification to PHP if there will be a change to benefits.

**Members must receive an updated SBC 60 days in advance of any changes to their benefit plan.** 

When do you distribute the SBC?

At the times required by the Affordable Care Act (ACA), including:

  • Initial enrollment - at new group implementation and to new hires throughout the year
  • Open enrollment - immediately upon confirmation of group’s plan decision for renewal 
Who is responsible to distribute the SBC?

The Employer Group is responsible for sending SBCs, either in paper or electronic format, to its employees, participants and beneficiaries. PHP will create the SBCs so that the employer can distribute SBCs to such individuals in a timely manner. 

How can you access the SBC?

Current SBCs are available online at www.phpni.com, on the Employer Portal under the Benefits/Contract tab. 

When will you receive an SBC?

Upon application - If a plan (including a self-insured group health plan) or an issuer distributes written application materials for enrollment, the SBC must be provided as part of those materials. For this purpose, written application materials include any forms or requests for information, in paper form or through a website or email, that must be completed for enrollment.

By first day of coverage - If there is any change in the information required to be in the SBC that was provided upon application and before the first day of coverage, the plan or issuer must update and provide a current SBC no later than the first day of coverage.

Special enrollment/enrollees - The SBC must be provided to special enrollees no later than the date on which a summary plan description is required to be provided (90 days from enrollment). A special enrollee is an eligible person who did not enroll during their open enrollment period, or a person who acquired a new dependent through marriage, birth or adoption.

Upon renewal - If a plan or issuer requires participants and beneficiaries to actively elect to maintain coverage during an open season, or provides them with the opportunity to change coverage options in an open season, the plan or issuer must provide the SBC at the same time it distributes open season materials.

Upon request - The SBC must be provided upon request for an SBC or summary information about the health coverage as soon as practicable but in no event later than seven business days following receipt of the request. 

Who is responsible for creating the SBC?

PHP is responsible for creating and delivering the SBC to the Employer Group, at no additional cost to members at renewal or for any mid-year plan change. For self-funded groups, the responsibility of creating the SBCs lies with the employer. 

What is a Summary of Benefit and Coverage (SBC)?

A short, easy-to-understand document provided to consumers that summarizes the key features of the plan or coverage they are considering or that they currently have. Think of it as the “Nutrition Facts” label of the health insurance industry. 

If I hire someone who resides outside of PHP’s coverage area, and the employee will not work within the coverage area, can they receive PHP health coverage?

In order to determine the feasibility of coverage for special employment situations, the following steps will apply:

  1. Contact your Account Manager
  2. Provide the details of the situation.
  3. Upon Underwriting approval, your Account Manager will work with you to determine the most appropriate network for the employee.
If an employee turns 65 and is still working full-time, does coverage change?

If an employee is age 65 or over and covered by a group health plan because of current employment or the current employment of a spouse of any age, Medicare is the secondary payer if the employer has 20 or more employees and covers any of the same services as Medicare. This means that the group health plan is the primary payer. The group health plan pays first on your hospital and medical bills. If the group health plan did not pay the entire bill, the provider should submit the bill to Medicare for secondary payment. Medicare will review what your group health plan paid for Medicare-covered health care services and pay any additional costs up to the Medicare-approved amount. The employee will be responsible for the costs of services that Medicare or the group health plan does not cover. If the employer has less than 20 employees, Medicare is primary. 

What happens if an employee is re-hired?

The effective date for a returning or rehired employee will be determined by the employer’s group contract. 

What happens when part-time employees change to full-time?

The effective date of coverage for part-time employees changing to full-time status is determined by the Employer’s Group Contract. Please refer to your Application for Group Contract.

What is required for Coverage through a Qualified Medical Child Support Order (QMCSO)?

When an employee is ordered to enroll himself/herself and/or a dependent child through a QMCSO, coverage shall be effective on the date the order is determined to be a QMCSO. We must receive a copy of the QMCSO and an Enrollment Form or Change Form to enroll the employee and/or the child.

How do I enroll employees outside of the open enrollment period?

If an employee or dependent does not enroll in the plan at the time they are first eligible, they may be eligible to come on the plan other than during open enrollment if:

  • A new dependent is acquired due to marriage, birth or adoption, or
  • An eligible employee or dependent was covered under another health plan and involuntarily loses coverage.

Refer to the Special Enrollment section of your contract for more information pertaining to special enrollment privileges under HIPAA. 

Is Extended Coverage available for Mentally and/or Physically Disabled Children?

An unmarried dependent child may continue on the plan beyond the dependent limiting age if:

  • The child is incapable of self-sustaining employment due to mental or physical disabilities,
  • The child is primarily reliant on the employee for support and maintenance,
  • Proof of incapacity and dependency is given to PHP within 120 days of reaching the limiting age, and
  • The child remains incapacitated and dependent, unless coverage otherwise ends under the contract.

Continued incapacity and dependency may be periodically verified at PHP’s discretion.

What is a Dependent?

  • The Subscriber’s legal spouse;
  • A child who is under 26 years of age and a United States citizen or legal resident of the United States and: 
    • A son or daughter of the Subscriber regardless of support level; or
    • A step-child, child subject to legal guardianship, grandchild or other blood relative who depends on the Subscriber for more than 50% of total support;
  • Any child of the Subscriber who is recognized under a Qualified Medical Child Support Order (QMCSO) as having a right to enroll under the Contract.
Does my group need to offer COBRA?

PHP is not a COBRA advisor, nor do we provide advice on this subject. However, federal guidelines state the following: “All employers who had 20 or more employees on 50% of their typical business day during the preceding calendar year MUST comply with COBRA. The only exceptions to this rule are: Federal Government and Church Plans (within the meaning of Section 414 (e) of the Internal Revenue Code.)”

When is Open Enrollment?

Open Enrollment is the period of time (usually one month prior to the group’s renewal) that is listed on the group contract that allows eligible employees who previously did not enroll, to come onto the plan and for those members enrolled to add, delete and/or make changes to their current coverage.

Certificate of Credible Coverage (COCC)

Credible Certificate of Coverage is required to prove prior coverage during a Qualifying Event. (Example: An employee loses coverage through his/her employer and now wants to be covered under the spouse’s plan. The CCOC will provide date coverage ended under prior carrier.)

What will the 1095-B Form look like?

Here’s an example of Form 1095-B.

We’re sorry; PHP is not able to answer tax questions or give tax advice.

When should I receive Form 1095-B from PHP? Do I need to wait on it to file my taxes?

Delivery of Form 1095-B

PHP will be issuing IRS form 1095-B to policyholders who carried PHP group health insurance coverage during 2017. These forms are targeted to be mailed by the end of January, 2018, however, the IRS deadline for delivery is March 2, 2018.

You need NOT wait on Form 1095-B to file your taxes!

Information on the form may help you prepare your taxes, however having the form in-hand is not required. You can use other information about your health insurance to complete your tax forms. (You must wait on Form 1095-A to file taxes; you need not wait on Form 1095-C).

Will my employer receive a copy of my form?

No. Form 1095-B will NOT be sent to employers. Policyholders receive the form AND the Internal Revenue Service (IRS).

What about my spouse and/or children?

If you have dependents (spouse or adult child) that you do not include on your tax return, you must provide a copy of Form 1095-B to them. PHP will supply copies of the form to policyholders only.

What if I receive more than one form?

You will receive only one form unless:

  • You had insurance coverage through more than one employer in 2017.
  • You had Off-Marketplace individual coverage for part of the year and through an employer for part of the year.
  • Your employer changed insurance providers mid-year.
  • Your employer changed names and/or Tax Identification Number (TIN).
What if my name has changed and my current name is not shown on the form I receive?

If your form has your Social Security Number (SSN)

Your SSN will be used to verify MEC against your tax return, so you will not need an updated form. However, for PHP's electronic transmission, your name must be submitted exactly as it has been registered with the IRS. Please contact PHP's Customer Service Department at 1-800-982-8257 to update your information.

If the form does NOT contain your SSN and therefore cannot be verified, please contact PHP’s Customer Service Department at 260-432-6690, Extension 16. We will update the form and send you a new form with your updated name.

Does everyone receive the 1095-B form?

All fully-insured PHP group policyholders will receive form 1095-B. Other forms include:

Form 1095-A, for Marketplace coverage

For answers to questions about 1095-A, call the Marketplace at 1-800-219-7214. This form is issued by the Federal Government.

Form 1095-C, for groups with 50 or more Full-Time Equivalent (FTE) employees

Form 1095-C questions must be answered by employers at the phone number listed on line 10 of the form. This form is issued specifically by employers that have more than 50 (FTE) employees.

What do I do with the 1095-B form PHP has sent me?

If you prepare your own taxes

Do NOT attach the form or send it with your taxes; keep it with your other important tax papers. If the form shows insurance for you and everyone listed on your tax return for the entire year, check the full-year coverage box on your tax return (located on line 61 of Form 1040, line 38 of Form 1040A or line 11 of Form 1040EZ).

If there are months when you or your family members did not have insurance you may be able to find helpful information at: https://www.irs.gov/. You may qualify for an exemption or you may have to make an individual shared responsibility payment.

If you don’t prepare your own taxes

Share the 1095-B form with your tax preparer.This will help them to file your taxes properly. Your 1095-B form is not required to file your taxes, however check with your tax preparer for their documentation requirements.

Why did I receive this form (1095-B) from Physicians Health Plan (PHP)?

As your health insurance partner, PHP is required to report insurance information (Section 6055) about you and your covered dependents (spouse and/or children) to comply with the Affordable Care Act (ACA). The ACA requires all Americans show proof of insurance (called Minimum Essential Coverage, or MEC) starting with their 2015 tax return filed in 2016, or pay a penalty unless subject to an exemption.

How do I get more information?

PHP's goal is to provide quality products and superior service. Questions about benefits, eligibility, claims payment, prior authorization, or the participation status of doctors, hospitals, or other facilities can be addressed by our Customer Service Department.

PHP Customer Service Department

260-432-6690, Extension 11
1-800-982-6257, Extension 11
260-459-2600 for the hearing impaired
custsvc@phpni.com

What should I do in case of an emergency?

PHP's definition of an emergency allows coverage for emergency room services that a reasonable person would consider dangerous to the patient's life or health. If a life-threatening medical condition occurs, call 911 or your local emergency service. If a non-life-threatening emergency occurs, contact your doctor for direction.

It is a good idea to discuss with your doctor what to do in the event of an urgent medical situation before it happens.

Is Physicians Health Plan my healthcare insurance company?

If your card has the PHP logo and purple coloring, Physicians Health Plan is your healthcare insurance company.

If your card is black and white with your company's name, Physicians Health Plan is not your healthcare insurance company. Your employer has a self-funded health plan and is financially responsible for payment of your benefits and determines what services are covered and at what benefit level. They have selected PHP Management Systems, Inc. (PHPMSI), a Third Party Administrator and a subsidiary of Physicians Health Plan, Inc., to manage and process medical claims on their behalf. Provider network participation may vary. Please refer to your Summary Plan Description or contact PHP's Customer Service Department for details.

What is PHP’s Reasonable & Customary procedure for members enrolled in POS benefit plans?

Physicians Health Plan provides "out of network" benefits for members enrolled in point of service benefit plans. With out of network benefits, members may use doctors and other health care providers outside of the PHP network. Payment rendered by PHP will be based on language in the member’s certificate of coverage that in most cases requires the amount to be either:

The In-Network Provider's standard rate adjusted by a geographical factor assigned to the location where the service was rendered; or

The out of network Provider's eligible billed charge.

PHP utilizes geographical factors established and used by the Centers for Medicare and Medicaid Services (CMS).

By using In Network provider rates and geographical factors, the maximum payment PHP allows for out of network claims will, at times, be less than the amount billed by a provider for a particular service. This may affect the member's out of pocket costs because the member is responsible for the difference between the out of network provider's charge and what PHP pays. This is known as Reasonable and Customary.

What if I need medical care that isn’t available from a doctor participating in the network?

A referral to a non-participating doctor may be obtained if a uniquely specialized procedure is medically necessary and not performed by any participating doctors. This process must be requested by your participating doctor and approved by PHP, in writing, prior to receiving the services.

How do I use Physicians Health Plan (PHP)‘s network provider directory?

Our provider directory helps you to find a doctor or a facility. Please be aware that this information is updated on a regular basis. To be certain a doctor is participating, ask the office staff prior to receiving care, or call the PHP Customer Service Department. Always show your ID card at each visit.

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