Today we have many choices regarding health insurance. There are a variety of managed care plans, which offer different types of coverage through products such as Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Point of Service (POS). Examples of the various products are Priority Health HMO, Blue Care Network HMO, M Premier Care HMO, Health Alliance Plan (HAP) HMO, Blue Choice POS, and Preferred Choices PPO. Understanding all the differences and making the best choice for you and your family can be a challenge.

Role of a Primary Care Physician

The role of your IHA primary care physician is to provide you and your family with comprehensive, quality health care. We are also your trusted guides through complicated medical and insurance systems. It is our responsibility to ensure your easy access to care by coordinating visits to specialists, admissions to hospitals, or other needed services. In working with numerous managed care companies, IHA physicians have realized that managed care plans offer patients significant positive benefits. At the same time, we have discovered that interpreting plan guidelines and requirements can sometimes be complicated and confusing.

IHA Patient Services Department

Recognizing this, IHA has developed a Patient Services Department, a team of trained representatives, to help IHA patients understand the requirements, cost differences, and benefits of a specific managed care plan. All patients in the IHA network have direct access to this valued-added service. The Patient Services Department serves as a liaison between you, your IHA primary care physician, and your managed care plan, to simplify your efforts to meet your health care needs. IHA physicians and the IHA Patient Services Department are continuously working to improve the delivery of managed care services to you. With your satisfaction as our goal, we look forward to this three-way partnership with you.

Obtaining Assistance 734-995-2950 (or toll free) 888-995-5677

As an IHA patient, you have direct telephone access to the Patient Services Department. Patient Service Representatives who are trained and knowledgeable regarding the specific requirements of managed care plans and insurers, staff our phones. Our phones are answered Monday through Friday, 8:00 am to 12:00 pm, 1:00 pm to 5:00 pm.

Expediting Your Call

Having the following information ready when you call Patient Services will expedite a Representatives ability to help you:

  • Your full legal name or the full legal name of the patient and date of birth
  • Telephone number with area code and the best time to reach you
  • Name of Insurance
  • Primary Care Physicians Name
  • Reason for the call

If all Representatives are busy, please utilize the voice mail system. All messages are retrieved throughout the day and a return call will be made to you within 24 hours. Please leave the above information in your message and a Patient Service Representative will be prepared when returning your call.

Services Available

The most frequent services requested of the Patient Services Department are obtaining referrals or authorizations for specialist services and outpatient procedures.

In addition, Patient Service Representatives can help you with the following:

  • Eligibility verification and benefit interpretation for specific plans.
  • Responses to general managed care inquiries by IHA patients and physicians.
  • Assistance with filing an appeal to an insurer for a denied service.
  • Any other concerns related to patient service.

Referrals and Authorizations

An important aspect of managed care is having your Primary Care Physician direct you through the health care system. It is your physicians responsibility to assess your health care needs and refer you to the appropriate specialist. If you seek the services of a specialist without an authorized referral, or have a service with a specialist who is out of network with your insurance plan, your insurer may not cover those services or you may be charged a higher co-payment. Referrals can be obtained at the time of your visit with your primary care physician, or by calling the Patient Services Department to request a follow-up visit with a specialist.

In-Office Referrals

To receive an in-office referral:

  • Your physician initiates the referral to a specialist at your visit.
  • The Patient Services Department processes the referral.
  • The referral is faxed to the insurance carrier or the specialists office within 48 hours of the issue date.

Referral Extensions or Follow-up Visits

To arrange for a referral extension or additional visits:

  • You contact the Patient Services Department by phone (Note: The Patient Services Department needs a minimum of 2 business days to process a referral. Please allow for this when contacting them prior to your scheduled appointment with a specialist.)
  • After obtaining approval from your physician, the Patient Services Representative processes your referral within 48 hours.
  • The referral is faxed to the insurance carrier or the specialists office within 48 hours.
  • A copy of the referral can be mailed to you but only at your request. BCN members will receive a copy of each referral by mail directly from the plan.

IHA BILLING ASSISTANCE

For questions pertaining to an IHA statement or bill.

Obtaining Assistance 734-997-7700 (or toll free) 877-977-9991

  • Your full legal name or the full legal name of the patient and date of birth
  • The IHA Account number you are inquiring about
  • Telephone number with area code and the best time to reach you.
  • Insurance carrier
  • Reason for the call

If all Billing Representatives are busy, please utilize the voice mail system. All messages are retrieved throughout the day and a return call will be made to you within 24 hours. Please leave the above information in your message so the Billing Representative will be prepared when returning your call.

Glossary of Managed Care Terms

  • Managed Care Network: A means of providing health care services within a defined network of health care providers who are given the responsibility to manage and provide quality, cost-effective health care to their patients.
  • HMO (Health Maintenance Organization): A managed care health plan in which your health care is arranged by your primary care physician (PCP) within a specific network of physicians and hospitals.
  • PPO (Preferred Provider Organization): A contract between insurance companies and care providers. The plan utilizes financial incentives for patients to obtain care from the preferred care providers. Additional fees are charged when care is obtained from non-participating providers.
  • POS (Point of Service): A plan offering a combination of features found in the HMO and PPO. Members can choose to use a participating or non-participating provider, but are usually charged an additional fee for choosing a non-participating physician.
  • Primary Care Physician (PCP): The doctor (most often practicing in Internal Medicine, Family Practice, Pediatrics, or General Medicine) you choose and designate to the plan to manage and direct your health care needs. This is the physician you see first for any health care need.
  • Open enrollment: A time period (usually once per calendar year) in which your employer offers you the option of changing your insurance coverage and/or options.
  • Provider directory: A listing of all the doctors, hospitals, and other providers who participate with a health plan. You should receive this directory from your respective health plan.
  • Referral: Documentation provided by your PCP that indicates your need for specialized services, scheduled hospitalization, or other medical care.
  • Requisition: A written order by the physician indicating what services need to be performed.
  • Precertification: A requirement of the admitting or ordering physician or patient to notify the managed care plan before the patient is admitted for inpatient care or an outpatient procedure.