If you have coverage under two or more health insurance plans, Providence will coordinate with the other plan(s) to determine which plan will pay for your Services. If you are in a situation where benefits need to be coordinated, please contact your customer service representative (800-878-4445) to ensure your Claims are paid appropriately.
Payments for most Services are made directly to Providers. If your Provider bills you directly, and you pay for Services covered by your plan, we will reimburse you if you send us your claims information in writing. See your Contract for details and exceptions. Payment will be made to the Policyholder or, if deceased, to the Policyholder’s estate, unless payment to other parties is authorized in writing.
Time frames for processing claims
Clean claims will be processed within 30 days of receipt of your Claim. We will send an Explanation of Benefits (or EOB, see below) to you that will explain how your Claim was processed. If Providence denies your claim, the EOB will contain an explanation of the denial. If we need additional time to process your Claim, we will explain the reason in a notice of delay that we will send you within 30 days after receiving your Claim. We will notify you again within 45 days if additional time is needed. If we need additional information to complete the processing of your Claim, the notice of delay will state the additional information needed, and you (or your provider) will have 45 days to submit the additional information. Once we receive the additional information, we will complete processing the Claim within 30 days.
Prior authorization of claims for medical conditions not considered urgent
Providence will let your Provider or you know if the Prior Authorization request is granted within two business days after it is received. If Providence needs additional information to process the request, we will notify you and your Provider within two business days of receipt, and you or your provider will have 15 days to submit the additional information. After receiving the additional information, Providence will complete its review and notify you and your Provider or you of its decision within two business days. If the information is not received within 15 days, the request will be denied.
Prior authorization for services that involve urgent medical conditions
Providence will notify your Provider or you of its decision within 72 hours after the Prior Authorization request is received. If Providence needs additional information to complete its review, it will notify your Provider or you within 24 hours after the request is received. Your Provider or you will then have 48 hours to submit the additional information. Providence will complete its review and notify your Provider or you of its decision by the earlier of (a) 48 hours after the additional information is received or, (b) if no additional information is provided, 48 hours after the additional information was due. If you fail to obtain a Prior Authorization when it is required, any claims for the services that require Prior Authorization may be denied.
For standard requests, Providence Health Plan will notify your provider or you of its decision within 72 hours after receipt of the request. For expedited requests, Providence Health Plan will notify your provider or you of its decision within 24 hours after receipt of the request. To qualify for expedited review, the request must be based upon exigent circumstances. See also Prescription Drugs.
Claims involving concurrent care decisions
If an ongoing course of treatment for you has been approved by Providence and it then determines through its medical cost management procedures to reduce or terminate that course of treatment, you will be provided with advance notice of that decision. You may request a reconsideration of that decision by submitting an oral or written request at least 24 hours before the course of treatment is scheduled to end. Providence will then notify you of its reconsideration decision within 24 hours after your request is received.
Timely submission of claims
Providence will not pay for Claims received more than 365 days after the date of Service. We will make an exception if we receive documentation that you were legally incapacitated during that time. Payment of all Claims will be made within the time limits required by Oregon law.
You will receive an explanation of benefits (EOB) from Providence after we have processed your Claim. An EOB is not a bill. An EOB explains how Providence processed your Claim, and will assist you in paying the appropriate member responsibility to your Provider. Copayment or Coinsurance amounts, Deductible amounts, Services or amounts not covered and general information about our processing of your Claim are explained on an EOB.
Premium payment due date and grace period
The Premium is due on the first day of the month. If you do not pay the Premium within 10 days after the due date, we will mail you a Premium delinquency notice. If the Premium is not paid by the last day of the grace period specified in the notice, your coverage will be terminated with no further notice on the last day of the month through which Premium was paid. We reserve the right to suspend Claims processing for members who have not paid their Premiums. Making a partial Premium payment is considered a failure to pay the Premium. If we do not send you the Premium delinquency notice specified above, we will continue the Contract in effect, without payment of Premium, until we provide such notice.
Advance premium tax credit grace period
Premium is due on the first day of the month. If you have a Marketplace plan and receive a tax credit that helps you pay your Premium (Advance Premium Tax Credit), and do not pay your Premium within 10 days of the due date in any given month, you will enter a “grace period” of three consecutive months.
During the first month of the grace period, Providence will pay Claims for your Covered Services received during that time. However, Claims for the second and third month of the grace period are pended.
If you do not pay all amounts of premium by the date specified in the notice of delinquency, you will be responsible for the Claims for any services received during the second and third months. Your coverage will end as of the last day of the first month of the three month grace period.
If you pay your Premiums in full before the date specified in the notice of delinquency, your coverage will remain in force and Providence will pay all eligible Pended Claims according to the terms of your coverage.
Prescription drug claims: During the first month of the grace period, your prescription drug claims will be covered according to your prescription drug benefits. During the second and third months of the grace period, your prescription drug coverage will be suspended and you will be required to pay 100 percent of the cost of your prescription drugs. If you pay all outstanding premiums before the date specified in the notice of delinquency, Providence will reinstate your coverage and reprocess your prescription drug claims applying the applicable cost-share.
Medically necessary services
We believe you are entitled to comprehensive medical care within the standards of good medical practice. Our medical directors and special committees of Network Providers determine which Services are Medically Necessary. Services that are not considered Medically Necessary will not be covered.
- Example: Your Provider suggests a treatment using a machine that has not been approved for use in the United States. We probably would not pay for that treatment.
- Example: You go to a hospital emergency room to have stitches removed, rather than wait for an appointment in your doctor’s office. We would not pay for that visit.
- Example: You stay an extra day in the hospital only because the relative who will help you during recovery can’t pick you up until the next morning. We may not pay for the extra day.
Although a treatment was prescribed or performed by a Provider, it does not necessarily mean that it is Medically Necessary under our guidelines. Calling customer service to obtain confirmation of coverage from Providence beforehand is always recommended.
Medical cost management
Coverage is subject to the medical cost management protocols established by Providence to make sure Covered Services are cost effective and meet our standards of quality. Such protocols may include Prior Authorization*, concurrent review, case management and disease management.
- We may use or share your information with others to help manage your health care. For example, we might talk to your Provider to suggest a disease management program that may improve your health.
- We reserve the right to deny payment for Services that are not Medically Necessary in accordance with our criteria. When more than one medically appropriate alternative is available, we will approve the least costly alternative.
- We reserve the right to make substitutions for Covered Services; these substituted Services must:
- Be Medically Necessary;
- Have your knowledge and agreement while receiving the Service;
- Be prescribed and approved by your Provider; and
- Offer a medical therapeutic value at least equal to the Covered Service that would otherwise be performed or given.
* If you fail to obtain a Prior Authorization when it is required, any claims for the services that require Prior Authorization may be denied.
Services provided by out-of-network providers
Typically, Providence individual plans do not pay for Services performed by Out-of-Network Providers. However, benefits for Covered Services by an Out-of-Network Provider will be provided when we determine in advance, in writing, that the Out-of-Network Provider possesses unique skills which are required to adequately care for you and are not available from Network Providers. Under no circumstances (with the exception of Emergency and Urgent Care) will we cover Services received from an Out-of-Network Provider/Facility unless we have Prior Authorized the Out-of-Network Provider/Facility and the Services received. Providence will only pay for Medically Necessary Covered Services. Please see your Benefit Summary for a list of Covered Services. You can check to see if a provider is in-network or Out-of-Network by checking the Provider Search page.
Your Plan only pays for Covered Services received from approved, Prior Authorized Out-of-Network Providers at rates allowed under your plan. If an Out-of-Network Provider charges more than your plan allows, that Provider may bill you directly for the additional amount. That amount is in addition to any Deductible, Copayment, or Coinsurance for which you may be responsible, and does not count towards your Out-of-Pocket Maximum.
Prescription drug benefit
The Prescription Drug Benefit provides coverage for prescription drugs which are Medically Necessary for the treatment of a covered illness or injury and which are dispensed by a Network Pharmacy pursuant to a prescription ordered by a Provider for use on an outpatient basis, subject to your Plan’s benefits, limitations, and exclusions. A list of covered prescription drugs can be found in the Prescription Drug Formulary.
Prescription drugs must be purchased at one of our network pharmacies
You access Providence Health Plan’s nationwide broad pharmacy network as published in our pharmacy directory. Providence Health Plan Participating Pharmacies are those pharmacies that maintain all applicable certifications and licenses necessary under state and federal law of the United States and have a contractual agreement with us to provide Prescription Drug Benefits. Please present your Member ID Card to the Participating Pharmacy at the time you request Services. If you have misplaced or do not have your Member ID Card with you, please ask your pharmacist to call us. All Covered Services are subject to the Deductible, Copayments or Coinsurance and benefit maximums listed in your Benefit Summary.
Use of out-of-network pharmacies
On rare occasions, such as urgent or emergency situations, you may need to use an Out-of-Network Pharmacy. If this happens, you will need to pay full price for your prescription at the time of purchase.
To request reimbursement, you will need to fill out and send Providence a Prescription Drug reimbursement request form. Please include any itemized pharmacy receipts along with an explanation as to why you used an Out-of-Network Pharmacy. Sending us the form does not guarantee payment.
Using your prescription drug benefit
If you choose a brand-name drug when a generic-equivalent is available, any difference in cost for Prescription Drug Covered Services will not apply to your Calendar Year Deductibles and Out-of-Pocket Maximums.
Participating Pharmacies may not charge you more than your Copayment of Coinsurance, except when Deductible and/or coverage limitations apply. Please contact customer service if you are asked to pay more or if you, or the pharmacy, have questions about your Prescription Drug Benefit or need assistance processing your prescription.
When purchasing a Prescription Drug, you may have to pay Coinsurance or make a Copayment. If the cost of your Prescription Drug is less than your Copayment, you will only be charged the cost of the Prescription Drug. You may need to make multiple Copayments for a multi-use or unit-of-use container or package depending on the medication and the number of days supplied.
You may purchase up to a 90-day supply of each maintenance drug at one time using a Participating mail service or preferred retail Pharmacy. Not all drugs are covered for more than a 30 day supply, including compounded medications, drugs obtained from specialty pharmacies, and limited distribution pharmaceuticals. To obtain prescriptions by mail, your physician or Provider can call in or electronically send the prescription, or you can mail your prescription along with your Providence Member ID number to one of our Network mail-order Pharmacies.
Upon Member or Provider request, the Plan will coordinate with Members, Providers, and the dispensing pharmacy to synchronize maintenance medication refills so Members can pick up maintenance medications on the same date. Members will be responsible for applicable Copayments, Coinsurances, and Deductibles.
Prescription drug formulary exception process
If your physician recommends you take medication(s) not offered through Providence’s Prescription Drug Formulary, he or she may request Providence make an exception to its Prescription Drug Formulary. Your physician will need to make a statement supporting why this request is necessary, and the Providence Pharmacy team will review and respond to your request within three business days, unless the pharmacy team requires additional information from your physician before making a determination.
Requests for exceptions to the Prescription Drug Formulary can be made using the Providence Prior Authorization Form, or your physician can write or call Providence to request an exception directly. Your provider will need to fill out the Drug Prior Authorization Request form. When submitting the form, please make sure your provider includes any medications previous tried and failed, chart notes from the last 6 months, and any medical rationale on why the formulary exception is being requested. Your physician may send in this statement and any supporting documents any time (24/7).
Expedited coverage determinations will be made if waiting the standard timeframe would cause serious harm to your health. Expedited determinations will be made within 24 hours of receipt.
Services that involve prescription drug formulary exceptions
Sometimes our members need access to drugs that are not listed on the plan's formulary (drug list). These medications are initially reviewed by Providence Health Plan through the formulary exception review process. The member or provider can submit the request to us by faxing the Drug Prior Authorization Request form. If coverage of the requested drug is denied, you have the right to appeal and then the right to an external review.
- For standard exception review of medical requests where the request was denied, the timeframe for review is 72 hours from when we receive the request.
- For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request.
If you do not agree with our denial of the non-formulary request through your internal member appeal, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision.
An IRO review may be requested by a member, member's representative, or prescribing provider by email, fax, mail or call listed in the following:
Providence Health Plan
Appeals and Grievance Department
P.O. Box 4158
Portland, OR 97208-4158
For standard and expedited exception review of medical requests where the request was denied, the timeframe for review is 72 hours from when we receive the request.
To request an expedited review for exigent circumstance, have your provider select the “Urgent Request” option in the Request Form.
For standard requests, Providence will notify your Provider or you of its decision within 72 hours after receipt of the request. For expedited requests, Providence will notify your Provider or you of its decision within 24 hours after receipt of the request. To qualify for expedited review, the request must be based upon exigent circumstances.
Denied exception requests
If your formulary exception request is denied, you have the right to appeal internally or externally. Please see Appeal and External Review Rights.
A request you or your provider makes to Providence to determine if a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Providence may require Prior Authorization for certain Services before you receive them, except in an emergency. Prior Authorization is not a guarantee of coverage. If you fail to obtain a Prior Authorization when it is required, any claims for the services that require Prior Authorization may be denied.
For Services that do not involve urgent medical conditions, Providence will notify you or your Provider of its decision within two business days after the Prior Authorization request is received. If additional information is needed to process the request, Providence will notify you and your Provider and you or your Provider will have 15 days to submit the additional information. Within two business days of the receipt of the additional information, Providence will complete its review and notify you and your Provider of its decision. If the information is not received within 15 days, the request will be denied.
Expedited prior authorization
For Services that involve urgent medical conditions: Providence will notify your Provider or you of its decision within 72 hours after the Prior Authorization request is received. If Providence needs additional information to complete its review, it will notify the requesting Provider or you within 24 hours after the request is received. The requesting Provider or you will then have 48 hours to submit the additional information. Providence will complete its review and notify the requesting Provider or you of its decision by the earlier of (a) 48 hours after the additional information is received or, (b) if no additional information is provided, 48 hours after the additional information was due.
Authorizations involving concurrent care decisions
Providence will notify you if an approved ongoing course of treatment is reduced or ended because of a medical cost management decision. You may submit a request to reconsider that decision at least 24 hours before the course of treatment is scheduled to end. Providence will then notify you of its reconsideration decision within 24 hours after your request is received. You can make this request by either calling customer service or by writing the medical management team.
Services requiring prior authorization
All inpatient admissions to a hospital (not including emergency room care), skilled nursing facility, or a rehabilitation facility, all emergency hospitalizations (we need to be notified within 48 hours, or as soon as reasonably possible) and all hospital and birthing center admissions for maternity/delivery Services; all outpatient surgical procedures; and certain infused Prescription Drugs administered in a hospital based infusion center.
Providence will provide a Prior Authorization form upon oral or written request. If you want more information on how to obtain Prior Authorization, please call Customer Service.
Prior authorization requests for out-of-network services
The Member or the Out-of-Network Provider must call us at 800-638-0449 to obtain Prior Authorization. Please have the following information ready when calling to request a Prior Authorization:
- The Member’s name and date of birth.
- The Member’s Providence Member number and plan number (these are listed on your Member ID card).
- The Provider’s name, address and telephone number.
- The name of the Hospital or treatment facility.
- The scheduled date of admission or date Services are to begin.
- The Service(s) to be performed.
Failure to obtain prior-authorization
Prior Authorization is a requirement for coverage of certain Covered Services under this Contract, even when the Covered Services are provided by In-Network Providers/Facilities. Prior Authorization is not a guarantee of benefit payment under this Contract and a Prior Authorization determination does not supersede other specific provisions of this Contract regarding coverage, limitations, exclusions and Medically Necessary Services. Under no circumstances (with the exception of Emergency and Urgent Care) will we cover Services received from an Out-of-Network Provider/Facility unless we have Prior Authorized the Out-of-Network Provider/Facility and the Services received.
If Providence finds a problem with a Claim (such as a duplicate or improperly coded Claim) after the Claim has been paid, Providence can retroactively deny the Claim to fix the problem. If you are being reimbursed directly for medical Claims, or if you have Pended Claims during a grace period, you may be impacted by retroactive denials. Also, if you are insured by more than one insurance company, there may be a dispute between Providence and the other insurance company which can also lead to a retroactive denial of your Claim (see Coordination of Benefits).
A retroactive denial may result in Providence asking you or your Provider to refund the Claim payment. You can avoid retroactive denial by making timely Premium payments, and by informing your customer service representative (800-878-4445) know if you have more than one insurance company that Providence needs to coordinate with for payment.
If you have made a payment in advance and then cancelled your insurance, or have made an accidental double-payment, please contact your Membership representative (888-816-1300) to request a refund.
Right of recovery
Providence has the right, upon demand, to recover from a recipient the value of any benefit or Claim payment that exceeded the benefits available under your Contract. Our right of recovery applies to any excess benefit, including, but not limited to, benefits obtained through fraud, error, or duplicate coverage relating to any Member. If timely repayment is not made, we have the right, in addition to any other lawful means of recovery, to deduct the value of the excess benefit from any future benefit that otherwise would have been available to the affected Member(s) from us under any Contract.
Advance Premium Tax Credit (APTC): A tax credit you may be eligible for (go to healthcare.gov to get a determination) to lower your monthly health insurance payment (or “Premium”). When you apply for coverage in the Health Insurance Marketplace, you estimate your expected income for the year. If you qualify for a Premium tax credit based on your estimate, you can use any amount of the credit in advance to lower your Premium. If you receive APTC, you are also eligible for an extended grace period (see Grace Period).
Claim: A request for payment that you or your health care Provider submits to Providence when you get drugs, medical devices, or receive Covered Services.
Coinsurance: Coinsurance means the dollar amount that you are responsible to pay to a health care Provider, after your Claim has been processed by us. Your Coinsurance for a Covered Service is shown in the Benefit Summary, and is a percentage of the charges for the Covered Service.
Contract: The agreement between you and Providence that defines the obligations of both parties to maintain health insurance coverage. You can find your Contract here.
Copayment: Copayment means the fixed dollar amount that you are responsible for paying to a health care Provider when you receive certain Covered Services, as shown in the Benefit Summary.
Covered Services: a Service that is:
- Listed as a benefit in the Benefit Summary and in your Contract;
- Medically Necessary;
- Not listed as an Exclusion in the Benefit Summary or in your Contract; and
- Provided to you while you are a Member and eligible for the Service under your Contract.
Deductible: Your Deductible is the dollar amount shown in the Benefit Summary that you are responsible to pay every Calendar Year for Covered Services before benefits are provided by us. Deductible amounts are payable to your Qualified Practitioner after we have processed your Claim.
Certain Covered Services, such as most preventive care, are covered without a Deductible. Please see your Benefit Summary for information about these Services.
The following costs do not apply towards your Deductible:
- Services not covered by your Contract;
- Services in excess of any maximum benefit limit;
- Balanced bills;
- Copayments or Coinsurance specified as not applicable toward the Deductible in the Benefit Summary.
Marketplace: The Oregon Health Insurance Marketplace, where people can shop for plans and receive tax credits, including Advance Premium Tax Credits, to help pay for their Premiums and Covered Services. You can obtain Marketplace plans by going to Healthcare.gov.
Medical Necessity: Services or supplies your medical care Provider needs to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Network Pharmacy: A pharmacy that has a signed a contractual agreement with Providence Health Plan to provide medications and other Services at special rates. There are four types of Network Pharmacies:
- Retail: A Network Pharmacy that allows up to a 30-day supply of short-term and maintenance prescriptions.
- Preferred Retail: A Network Pharmacy that allows up to a 90-day supply of maintenance prescriptions and access to up to a 30-day supply of short-term prescriptions.
- Specialty: A Network Pharmacy that allows up to a 30-day supply of specialty and self-administered chemotherapy prescriptions. These prescriptions require special delivery, handling, administration and monitoring by your pharmacist.
- Mail Order: A Network Pharmacy that allows up to a 90-day supply of maintenance prescriptions and specializes in direct delivery to your home.
Out-of-Network Provider: Out-of-Network Provider means an Outpatient Surgical Facility, Home Health Provider, Hospital, Qualified Practitioner, Qualified Treatment Facility, Skilled Nursing Facility, or Pharmacy that does not have a written agreement with Providence Health Plan to participate as a health care Provider for this Plan.
Out-of-Pocket Maximum: The total amount you will pay Out-of-Pocket in any Calendar Year for Covered Services received. The following Out-of-Pocket costs do not apply toward your Out-of-Pocket Maximum:
- Services not covered by your Contract;
- Services not covered because Prior Authorization was not obtained;
- Services in excess of any maximum benefit limit;
- Fees in excess of the Usual, Customary and Reasonable (UCR) charges; and
- Deductibles, Copayments or Coinsurance for a Covered Service if indicated in any Benefit Summary as not applicable to the Out-of-Pocket Maximum.
Pended Claim: A Claim that requires further information or Premium payment before it can be fully processed and paid to the health care Provider.
Policyholder:The policyholder must be at least 18 years old, is financially responsible for the policy and is the person authorized to make changes to the plan.
Premium: The monthly rates set by us and approved by the Director as consideration for benefits offered under this Contract. Premium rates are subject to change at the beginning of each Plan Year.
Prescription Drug Formulary: A list of drugs covered by Providence specific to your health insurance plan. You can find the Prescription Drug Formulary here.
Prior Authorization: A request to us by you or by a Provider regarding a proposed Service, for which our prior approval is required. Prior Authorization review will determine if the proposed Service is eligible as a Covered Service or if an individual is a Member at the time of the proposed Service. To facilitate our review of the Prior Authorization request, we may require additional information about the Member’s condition and/or the Service requested. We may also require that a Member receive further evaluation from a Qualified Practitioner of our choosing. Prior Authorized determinations are not a guarantee of benefit payment unless:
- A determination that relates to benefit coverage and Medical Necessity is obtained no more than 30 days prior to the date of the Service; or
- A determination that relates to eligibility is obtained no more than five business days prior to the date of the Service.
Provider: A physician, Women’s Health Care Provider, nurse practitioner, naturopath, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally licensed by the appropriate governmental agency to diagnose or treat an injury or illness and who provides Covered Services within the scope of that license. A Provider may be in-network for Providence members on a certain plan but Out-of-Network for other plans. You can find in-network Providers using the Providence Provider search tool.
Service: A health care related procedure, surgery, consultation, advice, diagnosis, referrals, treatment, supply, medication, prescription drug, device or technology that is provided to a Member by a Qualified Practitioner.
(See also your Individual Plan Contract)
If you disagree with our decision about your medical bills, you have the right to appeal.
Internal Appeal: You must file your appeal with Providence Health Plan in writing and within 180 days of the date on the Explanation of Benefits, or that decision will become final. If you are seeing a non-participating provider, you should contact that provider’s office and arrange for the necessary records to be forwarded to us for review. You may present your case in writing. Once a final determination is made, you will be sent a written explanation of our decision.
We will provide a written response within the time frames specified in your Individual Plan Contract.
- For Plans Issued in the state of Oregon:
If your appeal involves (a) medically necessary treatment, (b) experimental investigational treatment, (c) an active course of treatment for purposes of continuity of care, (d) whether a course of treatment is delivered in an appropriate setting at an appropriate level of care, or (e) an exception to a prescription drug formulary, you may waive your right to internal appeal and request an external review by an Independent Review Organization. Your request for external review must be made to Providence Health Plan in writing within 180 days of the date on the Explanation of Benefits, or that decision will become final. See your Individual Plan Contract for more information on external review.
How to Submit Your Appeal: Your written appeal should be sent to: Providence Health Plan, Appeals and Grievances Department, PO Box 4158, Portland, Oregon 97208-4158. You may fax your appeal to 503-574-8757 or 1-800-396-4778, or you may hand deliver it (if mailing, use only the post office box address listed above) to the following address: Providence Health Plan, 3601 SW Murray Blvd., Suite 10, Beaverton, Oregon 97005. If you would like to submit a verbal complaint or have questions about the grievance and appeal process, contact a Customer Service representative at 503-574-7500 or 1-800-878-4445. If you are hearing impaired and use a Teletype (TTY) Device, please call our TTY line at 711.
Assistance Outside of Providence Health Plan:
- Oregon Plans:
You have the right to file a complaint or seek other assistance from the Oregon Insurance Division. Assistance is available: by calling (503) 947-7984 or the toll-free message line at (888) 877-4894; by electronic mail at email@example.com; by writing to the Oregon Insurance Division, Consumer Advocacy Unit at PO Box 14480, Salem, OR 97309-0405; or through the internet at http://www.insurance.oregon.gov/consumer/consumer.html.