The following is designed to help you better understand your health plan coverage. For additional information, refer to your member materials available in the Providence Health Plan secure member portal, myProvidence.
Quality improvement program
Every year, our quality improvement program finds ways to help our members improve their health. We work to make sure members receive the high-quality care they deserve. Refer to the quality improvement program summary to learn how we are improving care and services for members. You’ll also see the progress we are making toward our quality improvement goals.
Benefits and services included in, and excluded from, coverage
Member materials, which include your member handbook and benefit summary or summaries, provide information about the benefits and services covered under your health plan; they also identify services that are limited and/or specifically excluded. Your member materials are available online in the Providence Health Plan secure member portal myProvidence, upon creation of a free account. If you prefer a printed copy of your member materials, please contact Providence Health Plan customer service.
Experimental, investigational and cosmetic services
Services determined to be experimental, investigational or cosmetic in nature are not covered by your plan. Your health plan may review services on a case-by-case basis to determine medical necessity. Learn more and see a list of services currently considered experimental, investigational or cosmetic (PDF).
Prescription drug information
Providence Health Plan prescription drug plans provide benefit payment for medications listed on the formulary* and which are:
- Medically necessary for the treatment of a covered illness or injury
- Prescribed by a qualified practitioner for use on an outpatient basis
- Filled by an in-network pharmacy
*A formulary is a list of FDA-approved prescription preferred brand-name and generic drugs. Designed to offer drug treatment choices for covered medical conditions, it can help you and your qualified practitioner choose effective medications that are less costly and that minimize your out-of-pocket expense.
Refer to the pharmacy resources page for more prescription drug information and to view formularies.
Copays and other charges for which members are responsible
The amount you owe for services rendered is listed in your member materials available in myProvidence. Generally speaking, those amounts may be in the form of:
- Coinsurance: A percentage of the cost of a covered service. The provider will bill you for the amount due, if any.
- Copay (also referred to as a copayment): The fixed dollar amount you pay for a covered service at the time care is provided.
- Deductible: The amount you pay out-of-pocket before benefits kick in. Deductibles are usually per person and/or per family, per calendar year.
- Noncovered services: Services not covered by your health plan.
- Usual, customary and reasonable (UCR): Should you receive services from an out-of-network* provider, you may be liable for the difference between the health plan payment and the provider’s actual charge.
* Personal Option plans do not offer out-of-network benefits.
How to obtain language assistance
For language assistance, please contact Providence Health Plan customer service at 800-878-4445 (TTY: 711).
How to submit a claim for covered services
Most providers will submit claims on your behalf to Providence Health Plan; however, if you need to submit a claim, forms, which contain submission information, are available in the Member section of this site.
How to obtain information about practitioners who participate in Providence’s provider networks
In-network providers are listed in the provider directory. For plan-specific results, search by member ID number.
How to obtain primary care services
The following provides a general overview of how to access non-emergent care under different plan types. Please consult your member materials for information specific to your plan.
- Choice or Connect plans: Under the Providence Choice and Providence Connect plans, a member must select a medical home. (A medical home is a specially designated primary care clinic in which a care team delivers patient-centered care focused on improving the health of the patient.) The medical home coordinates the care a patient receives from multiple providers and caregivers, and provides referrals as necessary.
- Personal Option plans: Personal Option plans require that services be rendered by an in-network provider.
- All other plans: Members may choose any qualified licensed provider; however, we recommended that members choose an in-network primary care provider because:
- In-network benefits are generally better than out-of-network benefits, resulting in lower out-of-pocket costs for members.
- In-network providers arrange any necessary prior authorizations, agree to file claims on the member’s behalf, and accept usual, customary and reasonable (UCR) charges (what's this?) as payment in full.
- While having a primary care provider is not required, studies show there are benefits to having an ongoing relationship with a primary care provider.
How to obtain specialty care, behavioral health care and hospital services
The following provides a general overview of how to access specialty care, behavioral healthcare, and hospital services under general plan types. For information specific to your plan coverage, please refer to your member materials available in myProvidence.
- Choice or Connect plans: A referral is required for all services except outpatient provider visits for mental health and chemical dependency and those services covered by a rider (e.g., dental, prescription drug, vision, and/or alternative care coverage). Some services, including inpatient hospital services, require prior authorization. Your medical home will provide referrals and arrange for any necessary prior authorizations.
- All other plans: Your primary care provider may refer you or you may refer yourself. To locate an in-network provider, please refer to the provider directory. Some services, including inpatient hospital services, require prior authorization. In-network providers arrange for any necessary prior authorizations.
How to obtain care after normal office hours
There are several ways to obtain care after office hours.
- Your primary care provider’s office will generally have a physician on call to respond to questions and/or provide guidance outside of normal business hours.
- ProvRN, 24/7 nurse advice line offered free to plan members offers access to a registered nurse who can assess your symptoms to help you determine next steps for care.
- Conditions that need attention right away but are not life-threatening (e.g., minor cuts or burns; ear, nose and throat infections; sprains or strains; headaches or dizziness) can be treated at an immediate (non-emergency) care facility.
- In the event of an emergency, call 911 or go directly to the nearest emergency facility. Urgent/emergent care is most appropriate for accidents or sudden, unexpected injuries or illnesses that may result in serious medical complications, permanent disability or death if treatment is not sought immediately (e.g., severe chest pain, loss of consciousness, bleeding that doesn't stop, severe abdominal pain, sudden paralysis or slurred speech, etc.).
How to obtain emergency care
Emergency care services are provided both in and outside of the service area. If an emergency situation occurs, you should take immediate action and seek prompt medical care. Call 911 or the emergency number listed in the local telephone directory, or go to the nearest emergency room. Learn more.
How to obtain care and coverage when outside of the service area
Providence Health Plan offers a national network of providers. To locate an in-network provider, refer to the provider directory. Covered services rendered by out-of-network qualified providers nationwide are eligible for benefits at the out-of-network benefit level. [NOTE: Personal Option plans do not offer out-of-network benefits.]
Emergency care for covered services is available worldwide for all plans.
Benefit restrictions that apply to services obtained outside Providence Health Plan’s service area
Benefits for otherwise covered services obtained outside the Providence Health Plan service area vary by plan type; please refer to your member materials in myProvidence for information specific to your plan.
After hours prior authorization requests
Providence Health Plan will begin processing non-urgent requests for prior authorization of services the next business day when such a request is received outside of normal business hours of 8 a.m. to 5 p.m., Monday through Friday.
How to voice a complaint
In the event you have a complaint, please contact Providence Health Plan customer service. Representatives are available to provide information and assistance. For more information, please refer to the Problem Resolution section of your member handbook.
How to appeal a decision that adversely affects coverage, benefits or a member’s relationship with the organization
Get information about filing an appeal and external review.