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Getting Care

Your Prime medical benefits start with your Primary Care Physician.

Your Primary Care Physician (PCP) takes care of you or refers you for care.

If you need to find a PCP, you can learn about Prime physicians and choose the one that’s right for you by using the online Find a Provider tool. Visit your local Prime Hospital website or www.primehealthcare.com

If you already have a PCP, please check the Find a Provider tool to be sure they are in Tier 1. If you have a PCP you prefer who isn’t in the Prime Tier 1 Provider Network, you can nominate them to join by emailing your request to EHPProvidercontracts@primehealthcare.com. Prime will send an invitation to the PCP and let you know if they become part of the network.

Your Primary Care Physician (PCP) takes care of you or refers you for care.

If you need to find a PCP, you can learn about Prime physicians and choose the one that’s right for you by using the online Find a Provider tool. Visit your local Prime Hospital website or www.primehealthcare.com

If you already have a PCP, please check the Find a Provider tool to be sure they are in Tier 1.

If you have a PCP you prefer who isn’t in the Prime Tier 1 Provider Network, you can nominate them to join by emailing your request to EHPProvidercontracts@primehealthcare.com. Prime will send an invitation to the PCP and let you know if they become part of the network.

The EPO Plan covers 100% of preventive care and most inpatient and outpatient hospital-based services at little to no cost when delivered by Prime Tier 1 Providers. There is no annual deductible. Copay and coinsurance are kept to a minimum. Prime also covers most of the monthly premium to keep costs low.

Members receive access to quality care by choosing a Primary Care Physician (PCP) in the Tier 1 Network. The Find a Provider tool, available here and on local Prime Hospital websites, makes it easy. Provider information is also available by clicking through the Tier 1 Provider Directory Files.

Knowing how your plan works, will make it easier to use your employee health benefits.

Next, let’s take it step by step

  1. Your Primary Care Physician (PCP) takes care of you or refers you for care.
  2. If needed, your PCP will refer you to another Prime Employed Provider or Tier 1 Provider.
  3. Go to that Provider and your care is covered under the Prime EPO. No Prior authorization is needed.
  4. Your PCP or Provider will request a Prior Authorization if you require a medical service that can’t be provided by a Prime Employed Provider or Tier 1 Provider, or if any service involves a non-Prime facility.
  5. Prime Utilization Management (UM) reviews all PAs to ensure quality care is provided in the right setting.
  6. UM approves 96 to 98% of PAs and then sends you and your Provider an approved authorization. Then you can make an appointment for care. When you go to that Provider, care is covered under EPO benefits.
    If the PA is denied, you or your PCP may dispute or appeal the decision.
  7. Next, claims for payment for your services are processed 3.96% of claims are processed within 24 hours.
    Keenan is the third-party administrator (TPA) that manages claim payment. Prime Claims Department audits claim payment to ensure accuracy and quality.
  8. For any questions, you can reach Customer Service from Prime and Keenan online and by phone. A complete list of who and when to call for service is later in this guide.

Continuation of Care

Under some circumstances, you may need Continuation of Care.

This allows you or a covered family Member to stay with your same Provider if you need critical care with continuity. Continuation of Care must be approved to be covered under your plan.
 

Conditions that qualify may include:

  • Third-trimester or high-risk pregnancies
  • Ongoing behavioral health services
  • Surgery/treatment approved to occur within 90 days
  • Terminal illness

How to request Continuity of Care

  • Ask your Provider about your need for Continuation of Care.
  • Your Provider will submit a request to Prime Utilization Management (UM).
  • UM will review the request and contact you and your Provider with approval or denial.