QUESTIONS & ANSWERS about POS Coverage

What is a Point of Service (POS) Plan?

The POS being offered to you through OSF HealthPlans is a plan that lowers your costs if you choose a Primary Care Physician from a preferred group of healthcare providers, and allows that physician to provide or arrange for all your healthcare needs. You may still use doctors outside the preferred list, but you will usually pay more to do so. Point of Service plans also apply the tools of HMOs, such as approvals for the use of certain medical services.

Do I have to call for preauthorization?

When you access care through your Primary Care Physician you do not need to call for preauthorization. You or your attending physician are responsible for obtaining prior approval for all services listed below when you are using a non-participating provider or when seeing a participating specialist without a referral from your Primary Care Physician. If covered by your plan, the following services require preauthorization:

• All inpatient stays

• All outpatient hospital surgeries

• Durable medical equipment

• Home health care

• Skilled nursing

• Physical/occupational/speech therapy

• Hospice

When these benefits are not preauthorized, your benefits will be reduced. Call the OSF HealthPlans HealthCare Management Department at 309-677-8236 or 800-284-2273 to obtain approval for the above services.

Will I need to file my own claims?

No. If you use a participating OSF HealthPlans POS provider, they will file claims for you. All you need to do is present your ID card at the time of your visit. However, you may be responsible for filing your own claims if you use a non-participating provider.

Can physicians bill me for costs above your reimbursement level?

Not if you are using an OSF HealthPlans participating physician or provider. A participating physician will always accept OSF HealthPlans reimbursement for covered services as payment in full after you pay any applicable copayment, deductible or coinsurance. You will be responsible if you are billed for services that are over our reimbursement level by any non-participating physician or provider not listed in our directory, unless it is an authorized referral from your Primary Care Physician.

Who do I call when I have questions about my POS coverage?

Our Member Services Department is available if you have a question regarding your coverage. Simply call 309-677-8222 or 800-673-5222.

DEFINITIONS

Primary Care Physicians are Family Practice, Internal Medicine and Pediatric doctors that provide and coordinate all your healthcare needs.

Participating providers are those under contract with OSF HealthPlans to provide services and include not only physicians and hospitals but also pharmacy and other designated individual services providers.

A referral is a method of preauthorization used by your Primary Care Physician.

A plan deductible is the amount you must pay before OSF HealthPlans begins payment for covered services.

Coinsurance is a cost-sharing arrangement in which you pay a percentage of the cost of medical care up to a yearly out-of-pocket limit.

Copayment is a type of cost sharing in which you pay a small dollar amount for a specific healthcare service.