The PPO plan design utilizes the Piedmont Community Health Plan network. This type of plan offers two levels of benefits, in-plan and out-of-plan. When a member utilizes network providers for covered services, they receive in-plan benefits. This is a higher level of benefits as compared to the out-of-plan benefits. Pre-certification is required for all hospital related services, including inpatient or outpatient care and diagnostic testing. When a member receives covered services from providers that are not in the network or without pre-certification, they receive out-of-plan benefits. This is a lower level of benefits which costs the member more out-of-pocket than the in-plan level of benefits.
Members are not required to select a primary care physician with the PPO plans. However, they are required to receive pre-certification for all hospital related services and should contact Piedmont within two business days of all emergency or urgent care visits. By doing so, they will receive in-plan benefits.
The PPO plans are offered to all employer groups with at least two full-time employees. Individual plans are not available at this time (Jan. 2014).
For more information on the PPO plans offered through Piedmont Community Health Plan or Piedmont Community HealthCare, contact us at (434) 947-4463. You can also click on PPO Frequently Asked Questions for more information.