About NCPPO

A regional leader, National Capital PPO (NCPPO) offers access to a broad network of physicians, hospitals and other health care professionals who have agreed to provide health care services at negotiated, discounted rates.

Nearly 120,000 individuals are enrolled in health plans that access National Capital's PPO network. NCPPO's service area includes the District of Columbia, Maryland, Virginia, Delaware, West Virginia and portions of New Jersey and Pennsylvania.

NCPPO's medical network serves nearly 120,000 enrollees who utilize the services of 20,000 physicians, 100 hospitals and 800 ancillary professionals. PPO enrollees have the freedom to choose any physician or health care facility, in or out-of-network, and in any state in which we do business. However, network physicians and facilities have agreed to accept discounted rates of reimbursement for treatment, so members who receive medical care within the PPO network have lower out-of-pocket costs and may receive higher benefits for covered services.

NCPPO's mental health network includes more than 1,100 physicians and facilities in Maryland, District of Columbia and Virginia. The Workers' Compensation network is comprised of more than 20,000 specialists and facilities in Maryland, District of Columbia and Virginia. The national dental PPO is offered in conjunction with WellPoint Dental.

Claim Repricing/Processing Activity
As a network service, NCPPO receives and reprices claims in accordance with the contract agreements with physicians or facilities. Afterwards, we forward the claims and worksheets to the claims administrator for benefit determination and payment. A repricing worksheet is produced for every claim. The worksheet shows the applicable contracted rate that corresponds to the billed service. NCPPO works with regional and national electronic claim vendors.

Responsive Customer Service
All NCPPO networks are supported by our service-driven philosophy. We build our programs around the needs of our clients and we support the programs with efficient, informed, accessible service. We offer toll-free customer service assistance to our physicians, hospitals and other health care professionals.

National Capital's PPO Quick Reference

Benefit Information
To verify benefit coverage for health services or patient eligibility, please contact the benefit administrator identified on the patient's enrollee ID card.

Customer Service Call Center
For inquiries about referral resources, claim status, and inquiries about benefit administrator phone numbers to verify patient eligibility or covered services, please call:

NCPPO Customer Service
314-989-6800 or toll-free 1-800-272-5911
Hours: 7:30 a.m. to 5:30 p.m. EST
Open business days.

Please Note: NCPPO PPO ID cards identify the office phone number of the benefit administrator. Questions regarding eligibility or benefit coverage may most efficiently be directed to the patient's benefit administrator.ID card for verification.

Network Services
For general information about programs, contracts, administrative services and credentialing information, please call your Network Services representative. If your representative is out of the office, you may leave a voicemail message or contact NCPPO's Customer Service Call Center for assistance and/or transcription of your inquiry:

NCPPO Network Services
703-914-5650 or toll-free 1-800-871-7888
Hours: 8:00 a.m. to 5:00 p.m. EST
Open business days.
Messages to Network Services representatives will be returned within two business days.

Claims Submission
Submit electronic claims through your electronic clearinghouse vendor:
Payor ID 90001

Submit paper claims to:
Specific PO Box and claim filing addresses listed on the patients' ID cards.

NCPPO/HealthLink
P.O.Box 419104
St. Louis, Missouri 63141-9104

Office Visit Co-payment
The office visit co-payment varies by employer group and/or payor. Typically, a specific dollar amount co-payment is indicated on the patient's member ID card if the plan coverage includes a flat co-payment. Collect this co-payment at the time of service. If the plan has a coinsurance percentage and/or deductible, the amount payable by the patient may vary as benefits are used during the plan benefit year. Coinsurance and deductibles usually are not printed on the patient's member ID card.
File your claim as directed on the patient's member ID card. The explanation of benefits will advise you and your patient of the expense paid by the health plan and the amount payable by the patient, if any. Practices are responsible for collecting any monies due from patients.

Appeals Submission
Claim denials, payment reviews (not pertaining to fee allowances), claim status, lack of pre-certifications, etc. should be directed to the claims administrator listed on the patient's member ID card.

For all other types of administrative, service and clinical appeals, please submit a typed explanation of the appeal consideration along with supporting information, and mail to:

NCPPO Appeals Division
P.O. Box 411424
St. Louis, MO 63141