FAQs

A Simple Guide to Using Your PPO Benefits

This page summarizes some of the most frequent questions members ask about Using Your PPO Benefits.  PacFed is dedicated to providing you with quality health care and service.  The more you understand how your Health Plan coverage works, the better your ability to use the services available. The Member Services Department is available to provide you with assistance when you need it. For more information or answers to other questions regarding coverage, please contact the Member Services Department at PacFed Benefit Administrators (PacFed).

  1. What is a Preferred Provider?
  2. How do I find a preferred provider physician?
  3. How do I use my medical identification card?
  4. What is an emergency?
  5. Where and how often can I get a prescription filled?
  6. What if I need to see a doctor while away from home?
  7. Do I have to receive prior authorization for certain services?
  8. How will my claims be paid?
  9. Will I have difficulty finding a PPO provider outside California?

1. What is a Preferred Provider?

A Preferred Provider typically accepts the health plan's Allowable Amount as payment for covered services. All you pay is your applicable Preferred Provider co-payment. Non-Preferred Providers can charge more than these amounts. When members use Non-Preferred Providers, they must pay the applicable co-payment plus an out-of-pocket cost, which is typically much greater than the cost to see a preferred Provider.

2. How do I find a preferred provider physician?

You may use any provider listed in the health plan's PPO Preferred Provider Directory. The PPO Provider Directory may be accessed online through this website.

3. How do I use my medical identification card?

You and your eligible dependents will each receive a medical identification card. Carry it with you at all times and have it available when you visit your doctor or have a prescription filled.

4. What is an emergency?

An emergency is defined as an illness that threatens a person's life.

5. Where and how often can I get a prescription filled?

Most prescriptions can be filled, in thirty-day supplies, at well-known chain drug stores. Long term medications can be purchased by mail. Call the health plan or PacFed Member Services for a mail order form.

6. What if I need to see a doctor while away from home?

You can also access the Provider Finder, an online provider directory on HealthNetís website at healthnet.com. Click on Find A Provider and scroll to the bottom of the page where you will see the First Health Provider link.

7. Do I have to receive prior authorization for certain services?

You are responsible for obtaining prior authorization for certain services, including inpatient surgeries, hospital stays and outpatient surgeries. If you have a life threatening emergency, however, please seek immediate care and then secure the necessary authorization.

8. How will my claims be paid?

When you use a PPO Preferred Provider, the service will be paid at the highest level and your co-payment minimized. The provider will send the claim to the health plan and receive reimbursement directly from the health plan. The health plan will send you a Explanation of Benefits detailing what was paid on your behalf.

9. Will I have difficulty finding a PPO provider outside California?

No. First Health, the national PPO provider for Health Net, coordinates with out of state providers. These providers are located on Health Netís website under the Provider Search area. Scroll down to the bottom of the page and click on the First Health provider link.

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