REIMBURSEMENT METHODOLOGY

Understanding How Your Plan Works
PerfectHealth’s High Deductible Health Plan allows you and your family members the freedom to choose any Provider at the time of service. However, you should keep in mind that the amount of benefit payable will be determined on whether the Provider is a PPO participating in-network Provider or a non- participating out-of network Provider. Your plan pays a higher level of benefits when you use the services of a participating in-network Provider.

When services are rendered by a participating in-network Provider, the Provider has agreed to accept a discounted rate from us. He has also agreed not to bill you the difference between the actual billed charges and the discounted rate. You are therefore responsible only for the discounted amount, which will be applied, to your annual deductible and coinsurance. Once your annual deductible and coinsurance limit are met, we will begin reimbursing you at 100% of the contracted amount.

When services are rendered by a non-participating out of network Provider, we will determine the allowed amount based on the reimbursement fee schedule that your employer has chosen .These reimbursement fee schedules are explained in detail below. We will then apply the allowed amount to your annual deductible and coinsurance. Once the annual deductible and coinsurance are met, we will reimburse you at 100% of the allowed amount. Keep in mind that non-participating out-of network Providers will often bill you a higher rate than what we will allow. You will then be responsible for the difference in what PerfectHealth allows versus what the Provider has actually billed you.

Explanation of Fee Schedules Applicable To Out-of Network Services
PPO
If your employer has chosen the PPO reimbursement fee schedule, medical care rendered by a non-participating, out-of network Provider will be based on a fee schedule established by using data developed by a premier health data research firm, Ingenix. This fee schedule is comparable to what we pay participating in-network Providers.

PPOplus
If your employer has chosen the PPOplus reimbursement fee schedule, medical care rendered by a non-participating, out-of network Provider will be reimbursed up to 200% of the PPO fee schedule.

When visiting with a non-participating out-of network Provider, we suggest that you first speak with the provider before services are rendered to get an estimate of what his/her charge will be. This will help you estimate what your out of pocket expenses will be.

To maximize your benefits and avoid greater out of pocket expenses, we urge you to always use participating in-network Providers for all services as you will not be responsible for the difference between what we allow and what the Provider has actually charged. If your Provider is currently not a participating in-network provider and they would like to join the network, they may do so by completing the form located in this binder under the section titled “Doctors”.

Important Note
The information provided here does not pertain to our EPO (Exclusive Provider Organization) plans, as there are limited out of network benefits available under the EPO plan such as, Emergency Care and Out of Area Dependent Care.

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