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1. May I choose my own doctor?
YES! You may choose any provider listed
in our Provider Directory or a provider that is not listed. If you select a provider who is not
listed in the SOUTH CENTRAL Preferred Provider Directory, your
employer may require you to pay more "out-of-pocket" expense for
your care. You should check with
your employer or TPA if you have questions about your benefits. If you are unsure which TPA your employer
uses, please refer to your identification card.
2. Do I need a referral form or pre-approval to see a
specialist?
NO! You may see the specialist of
your choice at anytime. If you
select a specialist who is not listed in the SOUTH CENTRAL Preferred
Provider Directory, your employer may require you to pay more
"out-of-pocket" expense for your care. You should check with your employer or TPA
if you have questions about your benefits.
If you are unsure which TPA your employer uses, please refer to your
identification card.
3. How will my physician or hospital know I am a SOUTH
CENTRAL Preferred member?
Your employer or TPA will provide you with an identification card that
displays our logo. Please show this
card any time you are seeking healthcare services.
4. Do any services/procedures need to be
pre-authorized/pre-certified?
SOUTH CENTRAL Preferred requires all participating providers to
pre-certify selected services for you. When you use a participating
provider, you are not required to pre-certify any service. If you use a non- participating provider
your employer may require you to pre-certify certain services. You should check with your employer or
TPA if you have questions about your benefits. If you are unsure which TPA your employer
uses, please refer to your identification card.
5. What services are covered by SOUTH CENTRAL Preferred?
Covered services are listed in the benefit plan your employer has
designed. You should check with your
employer or TPA if you have questions about your benefits. If you are unsure which TPA your employer
uses, please refer to your identification card.
6. Will I receive an “explanation of benefits” after my
claim has been processed?
Yes. Your Third Party
Administrator (TPA) will mail you an explanation of benefits which details
what the provider charged, what was approved, what was paid and what you
owe the provider. If you are unsure
which TPA your employer uses, please refer to your identification
card.
7. What is SOUTH CENTRAL Preferred's
relationship with my third party administrator (TPA) or payor?
SOUTH CENTRAL Preferred, a PPO, manages the delivery of your
health care. Our recommendations
will be given to your providers and your TPA. Final authority for determining what
services are covered under your employer's benefit plan resides with your
TPA. Our recommendations focus on
determining the appropriate level and setting for your care. If you are unsure which TPA your employer
uses, please refer to your identification card.
8. What is an “allowable fee?”
SOUTH CENTRAL Preferred has contracts with all participating
providers. These providers agree to
provide their services to our members for a negotiated price. We call this price the "allowable
fee". When using a
participating provider, you are never billed more than the allowable fee
for their services.
9. I don't have a SOUTH CENTRAL Preferred I.D.
card. How do I get one?
Identification cards are issued by your TPA. Please contact them if you need an
identification card. If you are
unsure which TPA your employer uses, please refer to your identification
card. If SOUTH CENTRAL Preferred
is your TPA, you may send us an
E-mail requesting a new identification card.
10. How do I submit a medical claim to SOUTH CENTRAL Preferred?
If you have SCP as primary coverage and you use participating providers,
they should always submit your claim for you. If you have SCP as secondary coverage,
you may have to submit the claim yourself to SCP. If you use a non-participating provider
or need to submit an SCP secondary claim, please submit his/her itemized
bill, with your member I.D. number printed next to your name. Our mailing address is P.O. Box 2347 York,
PA 17405.
11. Where should I send my dental and/or prescription
claims?
Each of our employers determines how dental and prescription claims are
handled for their employees. Please
contact your Personnel/Human Resources Department for an answer to this
question.
12. I have a claim that was denied or paid
incorrectly. Who should I talk to?
Your TPA is responsible for the payment or denial of claims. Please contact them to discuss these
issues. If you are unsure which TPA
your employer uses, please refer to your identification card.
13. Is my doctor a participating SOUTH CENTRAL Preferred
provider?
SOUTH CENTRAL Preferred's network of providers is the most
comprehensive in our area. To find
out if a specific provider participates in our network click here and you will go to
our on line provider directory.
14. What is COBRA and how does it effect me?
COBRA is a federal law that was passed
in 1985. It allows certain
individuals to continue to receive benefits under employer-sponsored health
plans even after those individuals are no longer employed by that
employer. To find out if you qualify
for COBRA benefits contact your Personnel/Human Resources Department.
15. What is a Third Party
Administrator (TPA)?
Employers who offer healthcare benefits to their employees have two
options. They can buy insurance from
an insurance company or they can provide the benefits themselves and hire a
company to administer their benefit plan. A TPA is a company that
administers benefits for self funded companies. Administration normally includes interpreting
the benefit plan, adjudicating claims, paying providers and answering
employee questions. SOUTH CENTRAL Preferred functions as a TPA for
several employers. If you are unsure which TPA your employer uses, please
refer to your identification card.
16. What coverage do I have when I am traveling
outside of Central Pennsylvania?
All of our employer groups provide some coverage for their employees
when they travel outside of Central Pennsylvania. To learn more about your coverage contact
your TPA. If you are unsure which TPA your employer uses, please refer to
your identification card.
17. What is a diagnosis and why is it needed to pay my
claim?
Your diagnosis tells your TPA the reason that you needed health
care. This is very important because
some benefit plans pay at different levels based on your diagnosis.
18. SOUTH CENTRAL Preferred sent me an
accidental injury form. Why?
We are the TPA for your employer and the diagnosis on your claim caused
us to issue this letter. Sometimes
another type of benefit should pay before your health care pays. Please
complete the form and promptly mail it back to us. This will allow us to process your claim
as quickly as possible. If you
prefer, you may complete an on-line accidental injury
form.
19. I received a coordination of benefits letter. Why?
We are the TPA for your employer. Once a year we need to check and see
if you have health care benefits available from any other source. We need
to make sure that if you have multiple coverages it works correctly. Please complete the form and promptly
mail it back to us. This will allow us to process your claim as
quickly as possible. You may
complete an on-line coordination of benefits form.
20. I believe my claim was
paid/denied improperly. How do I have this reviewed?
Any review or appeal must be conducted by your TPA. If you are unsure which TPA your employer
uses, please refer to your identification card. If SOUTH CENTRAL Preferred is your
TPA please send us a written description of the problem and how you believe
it should be resolved. We will review the issue, consider the information
you provided and provide you with our written response. If you would like to use E-mail to inform
us of an issue, please click
here.
21. I am receiving care as the result of an automobile
accident. The benefits provided by
my automobile insurance have run out. How do I submit future claims to
SOUTH CENTRAL Preferred?
Your automobile insurance should have sent you a letter indicating that
your benefits are now exhausted. Send us a copy of this letter with your
next claim. As you visit providers
in the future, please indicate to them that your coverage is now under
SOUTH CENTRAL Preferred. Our
mailing address is: P.O. Box
2347 York, PA
17405
22. I need to add a new dependent to my coverage. What
do I need to do?
You must contact your employer’s Personnel/Human Resources
Department to add someone to your
coverage.
23. What is a pre-existing condition and how does it
effect me?
A pre-existing condition is a medical problem that you had before you
were covered by your current benefit plan. Some benefit plans limit the
amount of coverage available for pre-existing conditions. To learn more about your coverage contact
your TPA. If you are unsure which TPA your employer uses, please refer to
your identification card.
24. What is a co-pay? What is co-insurance?
Some benefit plans require the beneficiary to pay for a portion of
his/her care. If the required
payment is a dollar amount ($5, $10, $20, etc.) it is called a co-pay. If the required payment is a percentage
of the cost (10%, 20%, Etc.) it is called co-insurance. To learn more about your coverage contact
your TPA. If you are unsure which
TPA your employer uses, please refer to your identification card.
25. Where can I find the Authorization for Release form?
Click on the Members tab. Click on
Forms. Click on the link for the Authorization
form. Print down the form, complete it
and fax it to our Customer Service department at (717) 851-6775.
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