FREQUENTLY ASKED QUESTIONS
For LocalSelect Point-of-Service (PPO) Plans
What Is Piedmont Community HealthCare?
Piedmont Community HealthCare, Inc., is a wholly owned subsidiary of Piedmont Community Health Plan, Inc. As part of the Centra Health System, Piedmont Community HealthCare offers network product options using Piedmont Community Health Plan's network of participating physicians and hospitals. Our offices are located at 2316 Atherholt Road in Lynchburg. Members may call our customer service representatives at 1-800-400-PCHP (7247) or locally at 434-947-4463.
How does a PPO (Preferred Provider Organization) plan work?
The PPO plan design utilizes the Piedmont 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.
Do you have to select a primary care physician?
No. Members are not required to select or receive services and referrals from a primary care physician in order to receive in-plan benefits. Members are not required to indicate a primary care physician on the enrollment/change form.
Is emergency care covered out of the area?
Emergency and urgent care is covered whether the member is in or out of the service area. As long as it is an emergency, care received from non-network facilities will be treated as in-plan. The member should contact Piedmont within 48 hours to receive the proper authorization for in-plan benefits. Routine care must be received from network providers in order to be covered in-plan.
If you have children away in college, how do they receive medical care?
Members who are outside of the area served by Piedmont, including college students, may receive in-plan benefits for urgent or emergency services that are needed while the member is outside of the network area. While routine services are not typically covered outside of the network area, Piedmont makes an exception for covered student dependents outside of the network area. These services are covered at the in-network level.
What is the difference between emergency care, urgent care and routine care?
Emergency care means care received as a result of a bodily injury or serious illness that threatens loss of life, limb or senses and requires the member to seek immediate medical attention. Emergencies include such illnesses as heart attacks, hemorrhaging, poisonings, and loss of consciousness and convulsions.
Urgent care means care received for a health problem usually marked by the rapid onset of persistent or unusual discomfort associated with an illness or injury. These problems may include high fever, vomiting, sprains and minor cuts. When outside of the Lynchburg area members with urgent care situations may seek care from the nearest available provider and contact Piedmont within 48 hours afterwards.
Routine care includes elective services and any other services that are for conditions that are not for emergency care or urgent care. Examples include office visits for consultations or for basic health services (such as treatment for chronic high blood pressure or routine gynecological care), any follow-up care necessary after receiving services for a medical emergency or urgent care situation, and ongoing conditions such as allergy shots or treatment of arthritis.
Is pre-certification required for any type of services?
Yes, pre-certification is required for all elective hospital services. This includes inpatient and outpatient care and diagnostic testing. Pre-certification can be obtained by contacting Piedmont. The proper telephone numbers are on the back of the member's ID card.
Are prescription drugs covered?
Yes, prescription drug coverage is offered with all PPO plan designs. Members must use participating pharmacies in order for the prescriptions to be covered.
How are pharmacy benefits administered?
Piedmont has developed a pharmacy network service using the services of a large national company called CVS/Caremark. A broad network of local pharmacies and national chain pharmacies participate in the CVS/Caremark pharmacy network. The network directory lists all participating pharmacies. To fill prescriptions members will need only to present their ID card and pay the appropriate copayment, deductible or coinsurance amount in order to receive prescription benefits.
Members can also receive prescriptions through a mail order program by completing the mail order form, enclosing an original copy of the prescription, and sending it to CVS/Caremark at the address shown on the mail order form. These forms can be picked up at the employer's office or by calling Piedmont at 1-800-400-PCHP (7247) or locally at 434-947-4463. Up to a 31-day or 100 unit supply is available each visit from the retail pharmacy while up to a 90-day or 300 unit supply can be received by mail order with each order.
NOTE: Certain walk-in pharmacies have contracted with CVS/Caremark and Piedmont to fill 90-day or 300 unit supply for the cost of mail order. Please contact these pharmacies listed in the network directory or on the website, www.pchp.net, to verify the benefit offering and find out the details on filling prescriptions.
Will I have to file claim forms?
Participating physicians will file claims for members when they receive in-plan services. Members may need to file their own claim forms for out-of-plan services.
How do I add coverage for a newborn child?
Newborn children of the female employee or male employee's spouse may be enrolled under the employee's coverage. Coverage will be effective as of the date of birth if the newborn is added within 31 days of birth.