Please CLICK HERE to download a copy of the detailed FAQs that provide information about the Authorization process and charts.
The Prime Healthcare Prime EPO Plan
Why have we designed the Prime Healthcare EPO Plan?
Prime Healthcare established a self-funded medical Prime EPO Plan for you, our valued employees. Providing you healthcare services at our own award-winning hospitals (Tier 1 Prime Healthcare Network) is an honor and allows us to offer high quality care to you and your families, and savings that are passed on directly to you at no or little cost with low out-of-pocket charges and minimal employee payroll contributions.
How does the Prime Healthcare EPO Plan compare to other medical plans?
The Prime Healthcare EPO Plan is among the best offered. It offers a high-quality plan and an award-winning network of hospitals and providers at the lowest costs to its members and provides value that is greater than a PPO plan. The Prime EPO Plan covers 100% of preventive care charges and most inpatient and outpatient hospital-based services within the Tier 1 Prime Healthcare Network, at little to no cost. Tier 1 includes Prime’s own award-winning hospitals and physicians and is growing daily to provide even more services. Most of all, the plan strives to provide exceptional care to employees and covered dependents, who are valued members of our own Prime Healthcare family.
What is the Tier 1 Prime Healthcare Network?
Physicians and Providers
Who is considered a Primary Care Provider?
A Primary Care Provider (PCP) is defined as: General Practitioner, Family Practice, OB/GYN, General Pediatrician and Internal Medicine. Establishing a primary care provider ensures you have a physician dedicated to coordinating your medical care and ensuring the quality of care you receive.
Where can I find a list of physicians in the Tier 1 Prime Healthcare Network?
The Tier 1 Prime Provider Directory is available on the EHP website at www.primehealthcare.com/EHP. If you need help with how to find a Tier 1 provider, please call Prime Customer Service at 877-234-5227 for assistance.
How often are the online Provider directories and the Find a Provider tool updated?
Why can’t I locate the Tier 1 Provider that I was directed to online?
How can my provider join the Tier 1 Prime Healthcare Network?
Do physicians pay a fee to join the Tier 1 Prime Healthcare Network?
Am I required to see a Tier 1 Prime Healthcare Primary Care Physician (PCP)?
When should I consider a Tier 2 PCP?
Am I required to see my PCP before I can see a Tier 1 Specialist?
Can I continue to take my children to the same Tier 2 Network Pediatrician?
Who should I contact to change my PCP?
Will I pay a higher copay if I designate a Tier 2 PCP?
How should my provider notify Prime UM of my referral? How long will it take Prime to approve or deny my referral?
Non-urgent referrals are generally processed within 7 – 10 business days and urgent referrals within 72 hours. For the status of a referral, please contact Prime Customer Service at 877-234-5227 or provider offices can log into the PAS (Prior Authorization System) referral system. The referring provider can sign up for the online automated PAS tool. PAS provides expedited referral turn-around times – nearly 60% of those received are auto adjudicated and approved within seconds of submission. To obtain a user ID and password, provider offices may send a request to EHP@primehealthcare.com. Referral requests can also be faxed to Prime UM at 909-235-4414.
Where can I find a list of covered services that can be performed in my doctor’s office without prior authorization?
The list is available at www.primehealthcare.com/EHP or members may contact Prime Customer Service at 877-234-5227 for a list of approved procedures performed in the provider’s office, not subject to the referral and prior authorization process. You may also request this information by emailing EHP@primehealthcare.com.
Does my PCP need to request prior authorization for lab tests associated with my annual preventative wellness exam?
No. Prior authorization is not required for routine annual preventative care, including mammography (3D mammography requires authorization), colonoscopy, annual physical, and preventive lab services, which are covered at 100%. Non-preventative services require a referral and prior authorization through Prime UM. A list of services that do not need prior authorization can be found on our website at www.primehealthcare.com/EHP.
Plan Benefits
How much will I pay for inpatient and outpatient care received at a Tier 1 Prime Healthcare Facility?
No charge for covered benefits! The Prime Healthcare EPO plan is one of the best in the nation with the lowest cost to members. The Prime EPO Plan pays 100% of charges for most inpatient and outpatient hospital-based services received at a Prime Facility! This means little to no out of pocket cost to you.
What if my provider wants me to receive services at a Non-Prime Facility?
How can I protect myself from surprise bills when I receive care from a non-Prime facility or provider?
My home is far from the closest Prime Healthcare Network facility. Do I have to travel to a Tier 1 Prime Healthcare facility, or can I use a Tier 2 facility closer to my home?
What if I am out of town and become injured or sick?
As a Prime member, you can receive care at any Prime facility across the nation. If your situation is an emergency, please dial 911 or go to the nearest hospital. If it is not a life-threatening emergency, call Prime Customer Service at 877-234-5227. This number is listed on the back of your Medical ID card. A Customer Service representative will assist you with locating a contracted provider to minimize the out-of-pocket costs to you. You can also locate Tier 1 Network providers and facilities at www.primehealthcare.com/EHP.
My dependent child lives outside of the Tier 1 Prime Healthcare Network service area. Is she still covered?
I have concerns regarding my privacy if I receive care at a Prime facility. What can be done to ease my concerns?
Every patient has the right to privacy. No matter where an employee works in the hospital, he/she must be aware and understand that all patients, including employees who are patients, have a right to privacy. This right is guaranteed under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
As a patient in the hospital, you have the right to control who will see and use your protected health information. This means that communications with or about your health information, including whether you are even a patient, will be private and limited to those who need the information for your treatment, payment, and healthcare operations. Prime Healthcare has a zero-tolerance policy regarding HIPAA violations.
Benefit*
What is the 1.5 Benefit?
The 1.5 Benefit was created to ensure that you and your covered dependents have access to comprehensive medical care at minimal out of pocket costs when available. If a Tier 1 Prime Facility or Tier 1 Prime Provider is not available in the Prime Network within a predetermined geographical distance (located in your benefits guide) of the Prime hospital/facility where you are employed, you and your covered dependents may be eligible for the 1.5 Benefit with Prime UM authorization. This means the applicable copay, coinsurance, or deductible would be the same as if you were receiving services at a Tier 1 facility or provider.
When does the 1.5 Benefit apply?
What if a service is not available in the Prime Tier 1 Network?
What if the care I need is not offered at a Tier 1 Prime Healthcare Facility?
To receive the 1.5 Benefit, do my provider or I need to request this benefit?
If my child needs emergency care and I choose to go to the nearest hospital, will the 1.5 benefit apply?
Always go to the nearest emergency room for medical emergencies. If a member is taken by ambulance to the emergency room, 1.5 benefits may apply. Keep in mind that Prime hospital emergency departments can provide emergency medical services for all pediatric patients. If transferred to another facility for admission or higher level of care, the emergency department will facilitate the transfer to ensure that quality of care is received. All emergency departments and emergency physicians are qualified to care for pediatric patients.
If a member elects to go to a non-network hospital emergency room because of personal preference, then Tier 2 out of pocket costs will apply and may be subject to additional costs, above the usual and customary billed amount.
Benefit Options for Eligible Members and Dependents: MERP and Medicare
Is there any benefit if I enroll in my spouse’s medical plan and opt out of the Prime Healthcare plan?
If I enroll in MERP, who is paying for my deductible, coinsurance, and copays?
If I receive a hospital bill, will MERP pay the entire cost?
How and when can I learn more about Medicare options?
Medicare is a federal health insurance program for people who are 65 or older. If you, your spouse or dependent is eligible for Medicare, it is helpful to consider all options before making your health insurance elections during your New Hire Enrollment or Prime’s Open Enrollment. The next Medicare Open Enrollment/Annual Election Period is from October 15 through December 7, during which time you may be eligible to sign up for a Medicare Advantage plan, switch from one Medicare Advantage plan to another, or drop your plan and return to Original Medicare (Part A and Part B). To learn more about Medicare, call 1-800-MEDICARE or visit https://www.medicare.gov/.
Can I still cover my spouse on a Prime Healthcare plan if he or she already has coverage through a retiree medical plan and is eligible for Medicare?
Referrals and Authorizations
What is the difference between a referral and an authorization?
A referral is the request the provider/physician submits to Prime UM as notification when referring a member for a higher level of care.
An authorization is an approval for the services requested from a referral. An authorization is often needed by providers or facilities to provide services to a member.
Who issues a referral and who issues an authorization?
A referral is issued by the physician/provider who is requesting further care for the member. Referral requests can be faxed by the physician/provider office to Prime UM at 909-235-4414 or via the PAS tool.
An authorization for Prime members is an approval given by Prime UM.
- For certain services, a referral is all that is needed
- For other services, such as Specialty care, a referral from the provider and a prior authorization from Prime UM is needed.
- Referrals are often sent by providers to Prime UM for review and authorization. Prime UM will issue an authorization based on its review.
- As a reminder, Prime UM handles all authorizations for services at non-Prime hospitals. The Blue Shield of CA/BCBS BlueCard Network cannot issue an authorization, so please make sure all your care is authorized through Prime.
Do I need a referral to access a Tier 2 facility for services?
How long will it take to get an authorization?
Non-urgent referrals are generally processed within 7-10 business days and urgent referrals within 72 hours. Many authorizations are now instantly and automatically approved. Prime Healthcare has built an automated platform (Prime Authorization System – PAS) for referral requests. More than 60% of specialty referrals are automatically approved with average turnaround times of two to three days for urgent authorizations and seven days for routine authorizations.
The PAS Tool is available for all physicians/providers to automate the referral process, and access can be provided by emailing EHP@primehealthcare.com. Referral requests can also be faxed to Prime UM at 909-235-4414.
Why am I being redirected to a provider within the Tier 1 Provider Network?
What should I do if the Provider that I was referred to can’t see me, and another provider within the same office can see me? Can I see that Provider without notifying Prime UM?
If I am pregnant and prefer to deliver in a Tier 2 facility, do I need to obtain a referral and prior authorization?
I have cancer and the Tier 1 Prime Healthcare Network near me does not have a cancer center. What should I do?
If I access an Urgent Care Center outside of the Tier 1 Prime Healthcare Network and lab work is required, will I need to return to a Prime facility for the lab work?
What labs and in-office procedures require Prime prior authorization?
Providers may reference the Prime approved labs and procedures that do not require Prime prior authorization on the approved procedures and labs list, available at www.primehealthcare.com/ehp. Examples of approved services include X-rays at the Orthopedic Surgeon’s office or urinalysis at the OB/GYN office. All labs and procedures not listed in the SPD as an approved service will require prior authorization from Prime UM.
What services require a referral or prior authorization from Prime UM for PCP and Specialist care?
Required | Tier 1 Prime Employed | Tier 1 Network Prime Healthcare | Tier 2 Network Blue Shield of CA/BCBS BlueCard |
|||
---|---|---|---|---|---|---|
Service | Referral | Authorization | Referral | Authorization | Referral | Authorization |
Primary Care Office Visit** General Practice, Family Practice, OB/GYN, Internal Medicine | N/A | No | N/A | No | N/A | Yes3 |
Pediatrician Office Visit | N/A | No | N/A | No | N/A | No |
Specialist Office Visit1 Initial Visit/Consult and Follow up visits | No | No | Yes | No2 | Yes | Yes3 |
PCP Lab Work In-Office Preventive/Routine | No | No | N/A | No | N/A | No4 |
PCP Lab Work In-Office Non-Preventive | No | No | N/A | Yes | N/A | Yes |
Auto-Approved Services Visit www.primehealthcare.com/EHP for a list of these services | No | No | No | No | No4 | No4 |
- Specialist Office Visits
Initial consults with Tier 1 specialists require a PCP referral, but do not require authorization or Prime UM Review.
- Tier 1 Prior-Authorization Not Required
Office visits (evaluation and management codes) *
Auto-approved codes (www.primehealthcare.com/EHP)*
US Prevention Task Force Preventive screening services (www.uspreventiveservicestaskforce.org/uspstf)
Facility-based services provided at a Prime facility*
* All Other specialty services not listed above will require Prior Authorization.
* Please verify benefits & review for services with a limited benefit.
- Tier 2 Authorization
If authorization to a Tier 2 provider is approved and Tier 1.5 benefits are applied:
- Three follow-up visits are approved within 365 days following the initial approved authorization date.
- A new authorization is required for follow-up visits after 365 days of initial approved authorization.
- All other services require prior authorization for each follow-up visit.
- Benefits may differ based on location with some locations not requiring authorization for Tier 2 PCP visits.
- Tier 2 Lab Work
All labs should be sent to a Prime facility or Prime-contracted LabCorp. All other labs require an authorization.
What services require a referral or prior authorization from Prime UM for Facility Services?
For detailed plan information, please refer to the Summary Plan Description (SPD). The following chart provides examples of when you need a referral or authorization:
Required | Prime Owned Hospitals/Facilities | Non-Prime Facilities | ||||
---|---|---|---|---|---|---|
Service | PCP Order or Prescription | Referral | Authorization | PCP Order or Prescription | Referral | Referral |
Imaging: MRI / CT / MRA/ PET scan / DEXA / Hospital Imaging | Yes | No | No | Yes | Yes | Yes |
Inpatient Hospitalization | Yes | No | No | Yes | Yes | Yes1 |
Outpatient Surgery | Yes | No | No | Yes | Yes | Yes |
Bariatric Services | Yes | Yes | Yes | Yes | Yes | Yes |
Sleep Studies | Yes | Yes | No | Yes | Yes | Yes |
Emergency Room Services | N/A | No | No2 | N/A | No | No2 |
Urgent Care | N/A | No | No3 | N/A | No | No3 |
Labs4 | Yes | No | No | Yes | Yes | Yes |
Auto-Approved Services Visit www.primehealthcare.com/EHP for a list of these services | Yes | No | No | Yes | Yes | Yes |
- Inpatient Hospitalization: Prime UM must be notified, and authorization is required for post stabilization care and inpatient hospitalization.
- Emergency Department Services: are to be provided at a Prime facility whenever possible, if rendered at a non-Prime facility Tier 2 rates may apply.
- Urgent Care: should be provided at a Prime facility ER or contracted urgent care facility whenever possible, if rendered at a non-Prime facility Tier 2 rates may apply.
- Labs: Any Lab Services should be sent to Prime Facility Lab or Prime Contracted Lab Corp
How to read your Referral?
Click here for the instructions.
The Prime Value Plan
If I am a Prime Value Plan member, will my referrals go through the Prime UM Department?
Am I required to stay within the Tier 1 Prime Healthcare Network?
Will I need a referral or authorization when seeking services in Tier 1 or Tier 2?
Yes. A referral from your PCP would be required in the same instances as the Prime EPO plan for specialty services and care. Please refer to the Summary Plan Description (SPD) for details. Remember, staying within the Prime Network (Tier 1) will result in less out-of-pocket costs to you.
Medical Emergencies
If I need to go to the Emergency Room, can I go to any hospital?
In an emergency, members should always go to the nearest hospital. Out-of-pocket payments are based on whether the facility is contracted as a Tier 1 or Tier 2 Provider, or out-of-network.
What if I am taken to a non-Prime Hospital Emergency Department and need to be admitted?
Prime UM reviews all cases to help coordinate your care and ensure you receive the care you need. If you are ever hospitalized, the hospital and provider must contact Prime UM to receive authorization, or the care you receive may not be covered. Once it is determined that you are clinically stable, we can help you return to the Prime Healthcare Network. Remember, staying within the Prime Healthcare Network this means lower out of pocket costs to you. Prime UM clinical care associates are available 24 hours a day, 7 days a week. The number can be found on the back of your medical ID card, or you can call Prime Customer Service at 877-234-5227 for assistance.
What if I am out of town and become injured or sick?
As a Prime member, you can receive care at any Prime facility across the nation. If your situation is an emergency, please dial 911 or go to the nearest hospital. If it is not a life-threatening emergency, call Prime Customer Service at 877-234-5227. This number is listed on the back of your Medical ID card. A Customer Service representative will assist you with locating a contracted provider to minimize the out-of-pocket costs to you. You can also locate Tier 1 Network providers and facilities at www.primehealthcare.com/EHP.
Claims and Explanation of Benefits (EOB)
What should I do when I get an EOB and it says I have a responsibility to pay?
Why wasn’t my claim paid?
Why was I sent to collections?
Prime Healthcare does not send members to collections. Providers may send members a bill and subsequently to collections if not resolved. Please reach out to your Provider directly, or the organization listed on the bill you received.
Please be sure to always open correspondence from Keenan and review your Explanation of Benefits (EOB). If the denial was issued in error, it can be corrected before the Provider sends to collections. Prime does not want any of our members to be directly billed by Providers for services that were approved and authorized by Prime UM or already paid by Prime. If this occurs, we will work to protect you and resolve this. Please call Prime Customer Service at 877-234-5227 and select the “Claims” prompt for assistance.
How to read my EOB?
Click here for the instructions.
Balance Billing
What is Balance Billing?
When providers bill a patient for the difference between the amount they charge and the amount that the patient’s insurance pays (excluding your deductible, co-pay and co-insurance).
Note: Balance Bills to our members are not bills from Prime/Keenan. Members receive bills from providers and facilities outside of Tier1 Network.
What are the top reasons for balance billing?
1. Receive services from a doctor, hospital, or other health care provider who does not have a contract or relationship with Prime (not part of Prime’s provider network).
2. Receive services that are not covered by Prime benefit plan, even if you’re getting those services from a provider that has a contract or relationship with Prime.
3. Receive services without required referral and prior authorization approval.
4. Receive services from out-of-network providers.
How to prevent from being Balance Billed?
- Understand your SPD, including but not limited to covered benefit, required prior authorization or required referral, member costs for non-Prime utilization, exclusions and limitations, and member responsible cost share.
- Use of only Prime facilities and Prime Tier 1 Provider network to protect you from higher cost care. Use the current Provider Directory available online. Prime UM/UR assists our members by redirecting the referral to Prime Tier 1 providers when available and appropriate.
- If services are provided by Tier 2 facilities, Tier 2 costs are often significantly higher than Tier 1 costs.
- Obtain prior authorization approval (see Referrals and Authorization section for additional details) before receiving the service, otherwise the service cannot be covered by Prime and providers may seek payment directly from members.
Note: Prime works to protect our members from the bills from outside providers and facilities, but if prior authorization or required referrals are not obtained, then Prime is unable to prevent these providers from billing our members. We will work to support and defend our members.
General Questions
If I need to make changes to my benefit elections, when can I make changes?
Is there a Customer Service Department that can help me with questions?
Yes! Prime Healthcare has a dedicated Customer Service Call Center designed to ensure prompt service. A phone prompt has been added to ensure that all urgent medical matters are addressed in real time.
The Prime Customer Service number is 877-234-5227. A dedicated email has been established for members to address all non-HIPAA questions: EHP@primehealthcare.com. Messages are responded to Monday through Friday, typically within 24 hours
Is Keenan Customer Service the same as Prime Customer Service?
No. They are two separate entities.
Keenan Customer Service (888-773-7218) oversees member eligibility, issues benefit verification for Providers, claims and appeals.
Prime Customer Service (877-234-5227) provides the status of referral and prior authorizations, facilitates urgent requests for authorization, oversees inpatient admissions, discharge planning, transfers, referral appeals, retroactive referral requests, provider finder, claim issues and prescription appeals.
How can I obtain a replacement or duplicate copy of my medical ID card?
Contact Keenan Customer service at 888-773-7218 or simply logon to www.keenan.com/benefits. You will need to establish an on-line account prior to utilizing this feature.
I have questions about my prescription coverage. Who I contact for help?
Please contact Express Scripts at 866-718-7955 or view your account online at www.express-scripts.com.
Who can I contact for assistance with my medical benefits at Prime Healthcare?
For: Utilization Review/Prior Authorization, Referrals and Referral Status, Provider Finder call Prime Customer Service: 877-234-5227
For: Benefits/ Eligibility/ Claims/ Appeals/ Provider Finder call Keenan Customer Service: 888-773-7218. www.keenan.com/benefits
Prime EHP Email Address: Any non-HIPAA related questions, send an email to EHP@primehealthcare.com
Prime UM General Fax (Referrals): 909-235-4414, Alternate Fax1: 909-235-4404, Alternate Fax2: 909-235-4427
Prime UM Concurrent Review/Inpatient Fax: 833-729-5928
EHP Prime Healthcare Website: www.primehealthcare.com/EHP
Tier1 Provider Finder: https://ehp.primehealthcare.com/find-a-provider/