1. What is Coordinated Health/Care™?
2. What is the TPA - Third Party Administrator?
3. How does Coordinated Health/Care work?
4. Does the program require me to use certain physicians?
5. Identifying a Primary Care Physician for each family member.
6. How do I know which physicians and facilities are "in-network"?
7. Why do I need referrals or pre-certifications?
8. Who issues the referrals?
9. What’s the impact on me if my physician is not in-network?
10. If I have an out-of-network primary care physician and he or she issues a referral for services, can I have my care covered at the in-network benefit level?
11. Do I need a referral for my annual gyn exam?
12. Do I have to see my primary care physician each time I need a referral?
13. If I have to see a specialist several times in the course of a treatment, do I need a referral for each visit?
14. Can I go to specialists on my own without a referral?
15. What if I have an emergency - do I need to have a referral?
16. What if I am already seeing a specialist or have a procedure already scheduled?
17. Do I have any more paperwork under this Plan?
18. Who do I call if I have questions?

1. What is Coordinated Health/Care? Coordinated Health/Care is a coordinated healthcare program that is incorporated into your company’s health benefit plan (the "Plan") and is operated in partnership with your local healthcare providers, many of which have agreed to participate in the program. The program comprises both a preferred panel of community providers and a care coordination program assisted by a staff of care coordinators. The program improves coordination and information among the many parties that are involved in healthcare activities, including the patient, one or more healthcare providers, and healthcare facilities such as hospitals and outpatient labs. By helping patients access the most appropriate healthcare resources in their community, providing information and guidance along the way, and making sure all the available information gets to the right place at the right time, Coordinated Health/Care has proven successful at increasing patient satisfaction while reducing cost for both employees and employers.

2. What is the TPA - Third Party Administrator? In addition to the community provider network and care coordination process, each plan incorporates a "TPA," or third party administrator, who is responsible for the claims payment and overall administration of the plan. Whereas the care coordination process will review many of your healthcare services to determine whether they meet the Plan’s criteria, the TPA makes all final determinations as to whether a service is a covered benefit, whether your are eligible to receive this benefit, and whether the expense will be paid by the Plan. In summary:

3. How does Coordinated Health/Care work? Each person in the program chooses a primary care physician to serve as their "coordinating physician." We encourage you to begin all healthcare inquires or events with a call or visit to this coordinating physician. Your coordinating physician can provide you with treatment, health information, and if necessary, refer you to other specialists or treatment facilities. This program also provides a team of Care Coordinators who support your physician as necessary to identify providers for needed services, approve referral and pre-certification requests as required by your benefit plan, and make sure all providers have all the information they need regarding your Plan and your care. Care Coordinators are also available to assist you with questions on these issues, and can be reached by calling .

4. Does the program require me to use certain physicians? No. You are free to choose physicians that are participating members of Coordinated Health/Care, or are members of the "wrap-around" network, which provides extended coverage. All of these providers are considered the "in-network" provider panel. You may also choose physicians who are "out-of-network" (e.g., not in either of the "in-network" provider panels). However, your benefit plan provides for a higher level of benefits when you choose to visit an in-network provider.

5. Identifying a Primary Care Physician for each family member. Under this Program, a primary care physician will serve as a "coordinating physician" for each patient to make certain that enrollees have access to all needed healthcare services. The coordinating physician also makes sure that all providers treating a patient have all of the information needed for the patient’s care. There is certain information that is sent back to the coordinating physician about all of the care a patient is receiving. For this reason, it is important that if you have a primary care physician, you make sure you list that physician’s name on the Primary Care Physician Designation form during enrollment. Following are some things to keep in mind:

6. How do I know which physicians and facilities are "in-network"? Your may check the latest list of in-network providers on this web-site. Depending on your browser, you may be able to print out the directory from this web-site. Also, your HR department will have updated copies of the provider directories for both the Coordinated Health/Care network providers and the "wrap around" network., or you can access the "wrap around" network’s provider panel network on-line.

7. Why do I need referrals or pre-certifications? Your community physicians use referrals and pre-certification as means of notification of patient needs. These notifications enable the community physicians to have all information on a patient and facilitate getting assistance to the physicians to keep care in-network to maximize your benefits and make sure you get the full range of services and are not left on your own to find services. In addition, referrals ensure that you will be seen faster by a specialist, as some specialists will not see new patients without a referral. These notifications also ensure in advance that treatment is a covered service under the Plan so there are no surprises for the patient (i.e., learning after the fact that a procedure is not covered due to being cosmetic or experimental).

8. Who issues the referrals? Generally, your coordinating physician, another physician in this physician’s practice, or primary care physicians covering for this physician will submit referral requests to the care coordinators on your behalf. During the course of obstetrical care, the patient’s ob/gyn is also treated as the patient’s coordinating physician for the purpose of issuing referrals.

9. What’s the impact on me if my physician is not in-network? When you visit an out-of-network physician, your benefits for the services provided by this physician will be paid at the out-of-network benefit level, as listed in the Schedule of Benefits document included in your benefits package, or found on this web-site under "Plan Documents." In this case, your physician will be paid at a rate which is generally lower than the in-network reimbursement. Out-of-network providers have not agreed to accept a certain fee for their services and generally "balance bill" the patient for the remainder of their bill. They may also require payment at the time of service, rather than billing the health plan directly. Please note, any extra amount that you pay the provider above the program’s reimbursement does NOT count against your deductible or coinsurance limits.

10. If I have an out-of-network primary care physician and he or she issues a referral for services, can I have my care covered at the in-network benefit level? Yes. Even though your visit to the out-of-network primary care physician is covered at the out-of-network benefit level, this physician can refer you to in-network specialists for further evaluation or treatment, and provided your physician submits a referral to our care coordinators, these referred services would be covered at the in-network benefit levels. If you identified an out-of-network primary care physician as your "coordinating physician", we will contact this physician by letter to advise them that you have identified him or her as your "coordinating physician," and to explain the program to him/her. We will provide this out-of-network physician all materials needed to submit referrals on your behalf. Please be aware that such out-of-network physicians are under no obligation to submit referrals, but if they do refer you to in-network providers and submit a referral to our care coordinators, your care will be covered at the in-network benefit level.

11. Do I need a referral for my annual gyn exam? For most plans, a referral is not needed for the annual Well Woman visit if this visit is with a ob/gyn or a gyn physician rather than your primary care physician. Please check your Plan documents to verify your plan’s policy.

12. Do I have to see my primary care physician each time I need a referral? Each primary care physician has different policies. You will have to ask your primary care physician how he or she wants to handle these situations. Generally, if you regularly see your primary care physician, he or she may issue referrals without requiring a visit, depending on your specific symptoms, etc. If, however, it has been several months or years since you have seen your primary care physician, it is likely they will want to see you for a general evaluation before issuing any referrals.

13. If I have to see a specialist several times in the course of a treatment, do I need a referral for each visit? No. The scope of the referral depends on what is needed as determined by your primary care physician and the referred-to specialist. Many times referrals are issued for "evaluation and treatment" with several visits or a time period noted in the referral for the evaluation and treatment of a specific condition. Generally, however, if you are referred to a specialist and the specialist determines that surgery or some other procedure is necessary, the specialist’s office will separately obtain a pre-certification for this procedure. The specialist’s office typically notifies one of our care coordinators of the surgery or procedure, and it is handled behind the scenes on behalf of the patient so you don’t have to do anything additional.

14. Can I go to specialists on my own without a referral? Yes, but you will not receive the highest benefits under your Plan. For example, if you are referred to an in-network specialist, your benefits will be covered at the enhanced benefit level. If you do not have a referral and you see an in-network specialist, your benefits will generally be covered at a lower level of benefits. If this specialist is an out-of-network provider, you will incur the total cost of this visit until you meet your deductible and could be responsible for your coinsurance after, based on your current out-of-network benefit level. You may also be held responsible by this out-of-network provider for any charges over the program’s reimbursement (see Question 8 above).

15. What if I have an emergency – do I need to have a referral? No. In the event of an emergency you should always go to the nearest medical facility. If you are treated at an emergency room for a legitimate emergency need, all services related to the emergency during the first 24 hours are considered automatically authorized. Your benefits will be paid at the stated benefit levels (in or out-of-network) regardless of whether a referral is in place. Following this emergency period, if you are admitted to a hospital, or need procedures or continuing care with a specialist as a result of this injury or illness, the facility or attending physicians need to submit a pre-certification. It is also best to advise your coordinating PCP. If you have difficulty reaching your coordinating physician, you or a family member may call our Care Coordinators () for assistance.

16. What if I am already seeing a specialist or have a procedure already scheduled? During initial plan enrollment you will be asked to complete a Health Needs Assessment survey. This survey asks you to identify if you or a family member is already in a course of treatment or has already scheduled services. During the initial plan enrollment only, our Care Coordinators will issue referrals and pre-certifications for such course of treatment or already scheduled services as long you have indicated this information in the survey. These "grandfathered" referrals will allow you to obtain the referral level of benefits for such services for a period of 90 days, after which your primary care physician will need to reissue such a referral. You will receive a letter regarding such "grandfathered" referrals and pre-certifications shortly after the effective date of this Plan. It is important that you carefully complete and return the Health Needs Assessment survey during enrollment.

17. Do I have any more paperwork under this Plan? No. The providers under the program send all referral and pre-certification requests, and we have designed our program so that it is easier for them to do so. You need to make sure that you always present your enrollment card to any provider you are seeing to make sure your providers know to obtain the necessary referrals and pre-certifications. However, you will not need to send in any forms or do anything else. If we have any questions or need missing information, our care coordinators will contact either your coordinating physician or you directly.

18. Who do I call if I have questions? If you have questions, please feel free to call our Care Coordinators at and they can assist you. One of our primary goals is to provide you with a source of information and remove the uncertainty that often accompanies healthcare events. Care coordinators are available Monday through Friday 8:30 a.m. to 5:30 p.m., but you can leave a confidential message at any time and we will return your call at the start of the next workday.