It’s important for members to understand how to navigate their healthcare options effectively. The information below serves as a guide for individuals seeking healthcare services within the PHCS and Multiplan networks, as well as those who need to navigate out-of-network care and reimbursement.

Here’s a summary of key points:

Informing Providers: If your chosen healthcare provider is in-network with PHCS or Multiplan, it’s essential to inform them that you are a member of these networks (PHCS or Multiplan). This information helps ensure that your expenses are processed correctly.

Payment at the Time of Visit:  All visit fees should be paid at the time of your medical appointment. Your member card, whether physical or digital, contains the necessary payor information for your provider to submit expenses for processing.

Out-of-Network Providers: If your preferred healthcare provider is not part of the PHCS or Multiplan networks, you can still see them. In this case, you will be considered a self-pay patient. You can request an adjustment, which can vary from 20% to 60% depending on your provider.

Required Information for Self-Pay and Reimbursement: When seeing an out-of-network provider as a self-pay patient, you’ll need to gather specific information for reimbursement. This includes:

• Provider’s Name, Address, and Phone number
• Provider NPI Number
• Provider TAX ID Number
• CPT Codes/Diagnosis Codes
• Amount Charged and Amount Paid
• A Provider-Issued UBO4, 1500 form, or “Super Bill”
• Proof of Payment for Services (Receipt of Voided Check)

 

Documentation Requirement: It’s important to note that itemized statements or patient portal screenshots will not be accepted as valid documentation for reimbursement. Ensure you provide the required information accurately.

Submission for Processing: Once you have gathered all the necessary information, you can submit your expense for processing through your member portal to receive reimbursement.

Following these steps will ensure a smooth process for the sharing of your medical needs. As a reminder, always check with your provider prior to your scheduled appointment if they are part of the PHCS or Multiplan network, if not, follow the steps for self-pay and documentation requirements.