What is a point-of-service (POS) plan?
A POS plan is a managed care program that combines the best features of an HMO plan with the freedom to choose. Just like an HMO, POS members choose a Primary Care Physician (PCP) who provides and coordinates care. When the member’s PCP coordinates care, members receive the highest level of coverage with low out-of-pocket costs. However, POS members also have the ability to seek care directly from any in-network or out-of-network provider without a referral. When members choose to use their self-referred benefit, they are responsible for additional out-of-pocket costs, such as deductible and coinsurance.
What is the difference between referred care and self-referred care?
Referred care references those services that are provided by or coordinated through your PCP. When your care is referred, you will receive the highest level of benefits, no deductibles and low copayments.
Self-referred references those services you receive directly from an in-network or out-of-network physician without a referral. You may be subject to increased out-of-pocket costs, as deductible and coinsurance apply, and you may need to submit your claims for reimbursement.
Am I responsible for the difference between the amount billed by a provider and the allowed amount when I self-refer?
In addition to your deductible and coinsurance, you will be responsible for the difference between the physician’s billed amount and the reasonable and customary amount when you self-refer to an out-of-network physician. If you self-refer to an in-network physician, you will only be responsible for the deductible and coinsurance for all covered services.
When I self-refer, who is responsible to preapprove my benefits?
If you choose to self-refer to any provider, you are responsible for contacting Patient Care Management by calling 1-800-227-3114 to obtain the necessary preapproval.
May I self-refer to an in-network physician?
You have the option of self-referring to an in-network physician. By doing this, you may be responsible for an annual deductible and coinsurance applied for all covered services.