Q. May I use any provider I choose under this Plan?
A. Yes, you can choose to see any provider. However, pre-certification or prior authorization is required for some services as indicated in the Certificate and your Schedule of Benefits. Use of Out-Of-Network providers for some services may not be a covered benefit or may be subject to deductibles, coinsurance, and/or co-payments. The level of benefit is determined by whether you use a network provider or an Out-Of-Network provider.
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Q. How do I obtain pre-certification?
A. You may obtain pre-certification by contacting our Managed Care Division at (800) 279-1301 or (608) 836-1400.
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Q. May I use network providers for some services and Out-Of-Network providers for others?
A. Yes, however, your coverage may change as you change providers, as explained in your Schedule of Benefits. Prior authorization and pre-certification requirements may apply.
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Q. Will I incur any liability if I fail to obtain pre-certification when it is required?
A. Yes, you will be responsible for 50% of covered services if you do not obtain pre-certification and these amounts do not apply toward satisfaction of the maximum out-of-pocket expense. Maximum allowable fees may also apply if an out-of-network provider is used.
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Q. Whose responsibility is it to provide the medical information that Dean Health Plan requires under the pre-certification provisions?
A. It is the member's responsibility to make sure this information is relayed to us. Any fees incurred due to release of this information is also the member's responsibility.
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Q. When should pre-certification take place?
A. You must contact our Managed Care Division for pre-certification of a planned, elective admission at least 10 business days prior to the planned admission date. This includes inpatient and outpatient admissions to hospitals, alcohol and drug abuse residential centers, skilled nursing facilities, and licensed ambulatory surgery centers. Be prepared to give information regarding your member number and the nature of your need for care.
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Q. What about emergency admissions?
A. In the case of an urgent/emergency admission, you must notify our Managed Care Division by the next business day for pre-certification approval.
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Q. What should be done in cases of maternity?
A. Our Managed Care Division must be notified in advance of your expected date of delivery for pre-certification of your maternity facility confinement. In addition, when you are admitted we must be notified by the next business day regardless of whether delivery of your baby has taken place or not (e.g., pre-term labor).
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Q. Who is responsible for any amount(s) charged by an Out-Of- Network provider that exceed the maximum allowable fee?
A. Payments for charges submitted by Out-Of-Network providers will be limited to the maximum allowable fee as defined in the Glossary Section of your Certificate and any amount(s) charged that exceed this limitation will be the member's responsibility.
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Q. If Dean Health Plan is closed and prior authorization is not possible, when must I notify the Managed Care Division of my outpatient emergency?
A. In most cases you will not need to notify our Managed Care Division of emergency outpatient care in advance. If you have an emergency procedure or admission that requires approval, you are required to contact us the next business day. Follow-up treatment after emergency care is also subject to the prior authorization requirements.
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Q. Do I need to decide at the time of enrollment whether I use network providers or can I decide this at a later date?
A. No, you are not required to choose a network provider at the time of enrollment. It is your option at any time to choose Network or Out-Of-Network providers. Note: there is a higher cost to you for Out-Of-Network providers.
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Q. Is there a different lifetime maximum coverage if I choose Network vs. Out-Of-Network providers at varying times?
A. No. Regardless of whether you choose network or Out-Of-Network providers, the Policy has a lifetime maximum benefit.
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Q. What are my responsibilities if my Network provider refers me to an Out-Of-Network provider? Do I need to obtain a written referral?
A. This plan does not require referrals. If you see an Out-Of-Network provider, the Out-Of-Network provider benefits will apply. However, certain types of care need prior authorization or pre-certification from our Managed Care Division. Please refer to your Schedule of Benefits.
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Q. Which deductible or co-payment applies if a network provider refers me to an Out-Of-Network provider?
A. The deductible or co-payment/coinsurance that you pay is determined by the participation of the provider you see. Please refer to your Schedule of Benefits.
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Q. My child is a full-time student. How can I ensure that my child will continue to receive coverage?
A. If a qualified dependent is a full-time student covered under a family Plan and has not reached the limiting age of a dependent as shown in your Schedule of Benefits, we will send a questionnaire to you each year. This form asks several questions so we can determine if your child is still eligible for coverage on your Policy. You must complete and return this form as soon as possible. If the questionnaire is not completed and returned, we will remove the student(s) from coverage under this Certificate. Claims would then be denied. In addition, it is in your best interest (and that of your children) to notify your employer or payroll department if full-time student status terminates. Failure to do so may result in the loss of continuation rights.
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Q. Do co-payments apply to the maximum out-of-pocket expenses?
A. No, co-payments do not apply to the maximum out-of-pocket expenses.
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Q. How will I know whether or not the deductible and/or maximum out-of-pocket expense on my Plan has been met?
A. If there is any liability on your part, you will receive an Explanation of Benefits (EOB) which will explain what has been paid by Dean Health Plan and what amount of the claim you are responsible for. The EOB will also indicate how much of the deductible and maximum out-of-pocket expense has been satisfied.
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Q. How can I find out about maximum allowable fees?
A. The EOB, which you will receive for every claim submitted from an Out-Of-Network provider, will explain the maximum allowable fee and your financial responsibility. You can find out the maximum allowable fee for a particular procedure prior to having a service performed. First, obtain from your provider the procedure code(s) and the amount(s) the provider will charge. Then, contact our Customer Care Center at (800) 279-1301 and request information about maximum allowable fees. Within 5 days of your request, we will advise you whether the service is fully covered and if it is subject to any Plan provisions (e.g., deductibles, coinsurance, co-payments or pre-existing conditions).
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Q. If I receive a denial for certain services, what can I do?
A. You have the right to appeal Dean Health Plan's decision. Please see the Complaint, Appeal, and Grievance Procedure Section of your Certificate for additional information.
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Q. If I lose coverage through my employer due to termination of employment, divorce, dependent reaching limiting age or for other reasons, how can I continue to receive coverage?
A. You may meet the eligibility guidelines of the State or Federal (COBRA) laws for group continuation. Please contact your employer and they will be able to assist you to determine if you are eligible. You may also contact Customer Care for assistance.
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