1. What is
a PPO?
A PPO (Preferred Provider Organization) is a group of physicians,
hospitals, and ancillary providers that have agreed to accept
a reduced fee schedule for medical services. These cost savings
are passed on to insurance carriers and employers as reductions
in medical expenses and/or reduced premiums. The medical providers
in the network benefit from a steady patient load and reduced
claims administration since NCPPO is essentially a clearinghouse
for many, many payors to the providers.
2.
Where do I submit claims for medical services?
YOU DON'T! For services rendered by an NCPPO physician, all
claims submissions are handled directly between the physician's
office and NCPPO. (For out-of-network claims, please check
your Benefit Plan or membership ID card for information on
claims submission.)
3.
How can I determine if my physician is in the NCPPO network?
NCPPO has an on-line Physician/Hospital Locator function.
This information is updated daily, but you should always
check with the provider's office and/or contact NCPPO to verify
that the physician's network affiliation has not changed.
Click here
to go directly to the Physician/Hospital
Locator.
4.
What do I do if my physician requires payment "up-front"?
Verify that the physician is an NCPPO participating physician.
If so, advise the physician that payment will be made directly
to the physician. If applicable, pay the co-pay only. NCPPO
does not determine benefits, but there could potentially be
some out-of -pocket expenses.
5.
My doctor is sending me a bill. Who should I call?
In certain circumstances it may be appropriate for a physician
to bill an unpaid amount for services rendered. Check your
Explanation of Benefits (EOB) that you receive from your insurance
carrier or administrator for the service date in question
for any outstanding balance and reasons. If you still have
a question, please call us with the date of service and the
provider's name or tax identification number. We will be happy
to look into the matter for you.
6.
How do I determine my benefits?
Reference the benefits booklet issued to you by your insurance
carrier/payor. If you still have questions, check the back
of your membership ID card for the telephone number to call
for customer service inquiries.
7.
Must I precertify care?
Precertification requirements vary. Insurance carriers do
offer health insurance plans that have precertification requirements.
It is best to check with your Employee Benefits Plan for detailed
information regarding your specific health insurance plan.
8.
What should I do if I have an emergency during non-business
hours?
If you have a medical emergency during non-business hours,
seek medical attention at the Emergency Department of the
hospital closest to you.
9.
If I am traveling and require medical attention, what should
I do?
The provider of service will probably require that payment
be made at the time the service is rendered. Present your
enrollee ID card to the provider so that a copy (front and
back) can be made.
Instruct the provider to mail
the claim to the claims mailing address indicated on the enrollee
card. The provider should note that you paid in full so that
your insurance carrier/payor will issue payment directly to
you. Additionally, some benefit plans contain Travel Reciprocity
programs. We encourage you to check with your health insurance
carrier/payor for specific instructions.
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