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Answers to Frequently Asked Questions from Members
Coverage for Students Away at School
In an emergency, what
should a student do?
What's
an emergency?
What
services are covered?
In
case of an injury or unexpected illness, what should a student
do?
If
a student needs care, but it's not urgent or an emergency, what
should he or she do?
Are
routine services covered?
Are
prescription drugs covered?
Should
a student carry a Preferred Care membership card?
If
a service costs less than it does in Rochester, why isn't it covered?
Coverage Outside Our Local Area or the Preferred Care Provider Network
What
should I do in an emergency?
How
do I know if I have an emergency?
What
does Preferred Care cover?
If
I'm injured or get sick, what should I do?
If I know I need care, but it's not really urgent or an emergency, what should I do?
Are routine medical services covered?
If a service costs less that it does in Rochester, why isn't it covered?
What
if I want care from a provider who isn't in the Preferred Care
network?
Are
prescription drugs covered?
Should
I carry my Preferred Care membership card?
Health Insurance in Addition to Your Preferred Care Coverage
When
do I use my other insurance coverage?
Who
pays first?
Billing Questions
If
I get a bill for services and I think Preferred Care should pay
it, what should I do?
Suppose
I already paid for these services?
Question:
In an emergency, what should a student do?
Answer:
First, the student should get medical attention immediately. Then,
the student's primary care physician should be contacted as soon
as is practical.
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Question:
What's an emergency?
Answer:
An emergency is a sudden, serious, and acute health problem. This
includes severe pain, or any symptom that might be expected to
cause impairment of functions or disfigurement.
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Question:
What services are covered?
Answer:
• Students are covered for emergency services. They are
also covered for services that have been arranged or authorized
by both their primary care physician and Preferred Care.
• If a student receives non-emergency services from a provider
outside the Preferred Care network, he or she is not covered unless
these services have been authorized in advance by both the student's
primary care physician and Preferred Care.
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Question:
In case of an injury or unexpected illness, what should a student
do?
Answer:
The student should go to the school's infirmary or health
center, even if he or she is not sure it's an emergency. If the
physician determines the student needs urgent care beyond what
can be provided at the school, the student must choose a local
doctor, then contact his or her primary care physician for approval of
an out-of-area visit.
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Question:
If a student needs care, but it's not urgent or an emergency,
what should he or she do?
Answer: Students seeking non-urgent care should
follow these criteria:
• For
follow-up care after an emergency or urgent treatment: the primary
care physician will contact Preferred Care to see if the care
will be covered.
• For a chronic condition: coverage is provided when approved
in advance by the Primary Care Physician and Preferred Care. Please
make these arrangements as far in advance as possible.
• For care not available from Preferred Care's network of
health care providers: if Preferred Care determines that care
is medically necessary, treatment by another provider may be authorized.
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Question:
Are routine services covered?
Answer:
Sorry, no. Routine care, treatment that the student
chooses to take but is not absolutely necessary, and diagnostic
services (such as eye or gynecological exams), are not covered
outside the Preferred Care service area. Students are expected
to take care of these services while at home.
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Question:
Are prescription drugs covered?
Answer:
Yes. Students may use their Preferred Care membership
card at any of the thousands of participating pharmacies in the
United States (You can find a participating pharmacy by calling
the Preferred Care Member Services Center.)
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Question:
Should a student carry a Preferred Care membership card?
Answer:
Yes. It provides coverage information as well as the
name of the student's Primary Care Physician.
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Question:
If a service costs less than it does in Rochester, why isn't it
covered?
Answer:
There are several reasons:
• When local physicians participate in Preferred Care programs,
they agree to provide services to our members at competitive rates.
Naturally, we honor these agreements.
• To make sure that you receive the best possible care,
we set high standards for training and service quality. When a
health care provider isn't part of our network, we can't be sure
our high quality standards will be met. That means we can't approve
their services.
• If complications arise, the costs of additional care can
be very high. Some out-of-area health care providers may charge
more than our participating providers. To be fair to all of our
members, we can't approve exceptions based on costs.
If you have questions about care outside our area, please call Member Services from 7am to 8pm (ET) Monday through Friday, at (585) 325-3113 or (800) 950-3224. TTY users may call (585) 325-2629 or (800) 252-2452.
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Question:
What should I do in an emergency?
Answer:
Get medical attention right away. Then contact your primary
care physician as soon as you can.
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Question:
How do I know if I have an emergency?
Answer:
An emergency is defined as a sudden, serious, and acute
health problem. This includes severe pain, or any symptom that
might be expected to cause impairment of normal functions or disfigurement.
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Question:
What does Preferred Care cover?
Answer:
Emergency services are covered. In addition, any services
arranged or authorized by both your primary care physician and
Preferred Care are covered.
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Question:
If I'm injured or get sick, what should I do?
Answer:
First, call your Primary Care Physician (PCP). Your PCP—or
a physician appointed by your PCP—is always available by
phone, even at night and on weekends. Your PCP can approve your
referral to an emergency room or another health care provider.
This way, your claim will be paid, even if it turns out it wasn't
an emergency.
Question:
If I know I need care, but it's not really urgent or
an emergency, what should I do?
Answer:
If your primary care physician and Preferred Care determine that
care is medically necessary but not available from a provider
in our network, evaluation and treatment by another provider may
be authorized.
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Question:
Are routine medical
services covered?
Answer:
Sorry, no. Three types of services are not covered: routine
care, treatments that you decide to take but that are not absolutely
necessary, and diagnostic services you receive from providers
that are not part of our network.
Exceptions
may be made in cases where you need ongoing care outside our service
area. Requests for exceptions must be made through your primary
care physician.
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Question:
If a service costs less than it does in Rochester, why isn't it covered?
Answer:
There are several reasons:
• When local physicians participate in Preferred Care programs, they agree to provide services to our members at competitive rates. Naturally, we honor these agreements.
• To make sure that you receive the best possible care, we set high standards for training and service quality. When a health care provider isn't part of our network, we can't be sure our high quality standards will be met. That means we can't approve their services.
• If complications arise, the costs of additional care can be very high. Some out-of-area health care providers may charge more than our participating providers. To be fair to all of our members, we can't approve exceptions based on costs.
If you have questions about care outside our area, please call Member Services from 7am to 8pm (ET) Monday through Friday, at (585) 325-3113 or (800) 950-3224. TTY users may call (585) 325-2629 or (800) 252-2452.
(Back to Top) Question:
What if I want care from a provider who isn’t in the Preferred
Care network?
Answer:
With few exceptions, it won't be covered. If your primary care
physician and Preferred Care both agree that your specific treatment
is necessary, and no one in our network can provide it, we'll
work together to find a provider that's qualified.
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Question:
Are prescription drugs covered?
Answer:
Yes. And to get lower Preferred Care prices and avoid
more paperwork, you should use your Preferred Care membership
card at one of the thousands of participating pharmacies in the
United States (You can find a participating pharmacy by calling
the Preferred Care Member Services Center.)
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Question:
Should I carry my Preferred Care membership card?
Answer:
Yes. It provides coverage information as well as the
name of your primary care physician. Our Member Services Center
can provide more membership cards if you need them.
Question:
When do I use my other insurance coverage?
Answer:
You'll need to coordinate your Preferred Care coverage
with coverage provided by your other health insurance. By coordinating
all the benefits you're entitled to, you help keep health care
costs more affordable for everyone.
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Question:
Who pays first?
Answer:
How benefits are coordinated depends on the specific
rules that apply to your situation and the types of coverage you
have. We may cover you as usual while your other insurance helps
pay for part of your care. Or, if you receive care not covered
by Preferred Care, your other insurance may pay for the entire
bill.
It can get
complicated but usually your other insurance company will settle
its share of the payments directly with Preferred Care and you
won't have to get involved. But you should know that if payments
owed to Preferred Care are sent directly to you, you are required
under Medicare law to give this payment to Preferred Care.
Please keep
us up to date. If you have health insurance besides Preferred
Care, or your coverage changes, it's very important that
you let us know.
Please make
sure you let us know about:
• Employer's group health insurance—your own or your
spouse's, for employees or retirees
• Workers' compensation due to a job-related illness or
injury (including the Federal Black Lung Program)
• No-fault or liability insurance following an accident
• Medicaid
• Tricare for Life (veteran's benefits)
• Dental insurance
• Prescription drug coverage
• COBRA continuation coverage—keeps coverage in effect
when employees leave a group health plan
If you have any questions about how we coordinate benefits, please
call Member Services.
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Question:
If I get a bill for services and I think Preferred Care should
pay it, what should I do?
Answer:
If you received emergency, urgently needed, or renal
dialysis services from a provider that is not part of the Preferred
Care network, you should ask us to pay the bill.
Before we
can pay, you must send us the original, itemized bills, which
include the:
• Diagnosis
• Date of service
• Provider's name/address/phone number
• Provider's tax identification number
• Listing of each service
• Charge for each service
Without the
original bill, we won't be able to help you.
Send your
request for payment to:
Preferred Care
c/o Claims Department
220 Alexander St.
Rochester, NY 14607
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Question:
Suppose I already paid for these services?
Answer:
If you paid for medical services and you think we should
reimburse you, follow the instructions above and, in addition,
include written proof of your payment along with your request.
Preferred Care will reimburse you for your payment minus your
co payment.
Please note:
• A request for payment for medical services that you received
between October 1, 2002 and September 30, 2003 must be filed by
December 31, 2004.
• If the provider is billing us directly, the bill should
be sent to the address above.
If you have questions about a bill, please call Member Services from 7am to 8pm (ET) Monday through Friday, at (585) 325-3113 or (800) 950-3224. TTY users may call (585) 325-2629 or (800) 252-2452.
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