HomeMy WebLinkAboutRESPONSE - RFP - P682 BENEFITS (11)PART D: USING THE PLAN
IN -NETWORK
OUT -OF -NETWORK
36. Does the enrollee have to obtain a referral and/or prior
No.
No.
authorization for specialty care in most or all cases?
37. Is prior authorization required for surgical procedures and
Yes.
Yes.
hospital care (except in an emergency)?
38. If the provider charges more for a covered service than the
No.
Yes.
plan normally pays, does the enrollee have to pay the
difference?
39. With respect to network plans, are all the providers listed in
Yes.
Yes.
Question 7 of this form accessible to me through my primary
care physician?
40. What is the main customer service number?
(800) 255-1180
41. Whom do I write/call if I have a complaint or want to file a
Write to: PacifiCare PPO/Indemnity Appeals
grievance?
Dept., 6455 S. Yosemite St., Englewood, CO
80111
42. Whom do I contact if I am not satisfied with the resolution of
Write to: Colorado Division of Insurance, ICARE
my complaint or grievance?
Section, 1560 Broadway, Suite 850, Denver, CO
80202
43. To assist in filing a grievance, indicate the form number of this
Policy Form 12345, Group -all sizes.
policy; whether it is individual, small group, or large group;
and if it is a short-term policy.
PART E: HOW PHYSICIANS ARE PAID. This section contains summary information about physician reimbursement.
To find out how a particular provider is paid under this plan, ask that provider.
IN -NETWORK
OUT -OF -NETWORK
44. What are the three most frequently used methods
99% Fee -for -service (provider
100% Fee -for -service
of payment for primary care physicians? Indicate
is paid each time he/she treats
(provider is paid each time
the approximate percentage of physicians paid
you). 1% Per case.
he/she treats you).
using each of the identified methods.
45. What are the three most frequently used methods
99% Fee -for -service (provider
100% Fee -for -service
of payment for physician specialists? Indicate the
is paid each time he/she treats
(provider is paid each time
approximate percentage of specialists paid using
you). 1 % Per case.
he/she treats you).
each of the identified methods.
46. What other financial incentives determine
No additional provider
No additional provider
physician payment?
financial incenti-ves.
financial incentives.
An Access Plan detailing the managed care network is available upon request. Please call Customer Service at (800)
255-1180 for more information.