How to use your benefits

Review the Annual Subscriber Notification to learn how to access care and make the most of your benefits.

Welcome to Providence

We encourage you to maximize your plan membership. Start here:

• Keep your member ID card close – You'll need your ID card when you receive services.
• Register for your myProvidence account – This is where you’ll find 24/7 access to your member information.
• Choose your primary care provider / medical home – Use the provider directory to find in-network physicians, facilities, and pharmacies.
• Explore your care options – Learn where to go for routine, immediate and emergency care.
• Review your plan benefits – Understand coverage, the claims process, and your portion of costs.
• Make the most of member perks – Tools and programs to help you achieve your health and wellness goals.

Pro tip: Your member materials and related information are available in myProvidence.

The Providence Health Plan Care Management team will help you better understand your health so you can take an active role in improving it. Whether you need help understanding a new diagnosis or assistance navigating healthcare services in your area, Providence Care Management is here to help.

Care Management services are voluntary, open to all Providence Health Plan members, and available at no cost. Members may self-refer or be referred by providers, caregivers, hospital discharge planners or as a result from a recent hospital stay or diagnosis. See a list of conditions supported by Providence Health Plan Care Management and learn more about the resources available to you based on your specific condition. You may also call Providence Health Plan Care Management at 800-662-1121 (TTY: 711) Monday through Friday, 8 a.m. to 5 p.m. (Pacific Time), or email caremanagement@providence.org to learn more and/or for additional assistance.

Quality Management Mailer Program

Providence Health Plan strives to improve member health outcomes by ensuring they receive recommended screenings. Our member mailing program aims to increase completion of these important screenings through both education mailings and gap mailings. Members who are eligible for screening according to clinical guidelines are sent mailers encouraging collaboration with their health care provider to ensure that appropriate testing is completed. Eligibility varies by mailing; members may meet criteria for more than one mailing.

Member mailings address a broad number of recommended clinical care, including:

• Adolescent and childhood wellness
• Blood pressure management
• Breast, cervical, and colorectal cancer screening (including FOBT)
• Diabetes and HbA1c
• Immunizations and vaccinations
• Respiratory health
• Women’s health
• Statin therapy

Opioid Safety Program

Your safety matters. Opioids can carry risks—even when taken as directed. If you are taking opioids, you may receive a letter with guidance to discuss with your provider.

Questions? Call Providence Health Plan Pharmacy Services at 877-216-3644, 8 a.m. to 6 p.m. (Pacific Time), Monday through Friday.

If you have a concern or disagree with a coverage decision, we’re here to help. Give us a call at the phone number listed on your member ID card.

Learn more

Know what to expect from us—and what we ask from you.

Nobody knows more about your health than you and your doctor. We take responsibility for developing plan benefits that serve you well; your responsibility is to know how to use your benefits. Please take time to read and understand your benefits. We want you to have a positive experience with Providence Health Plan and we're ready to help in any way.

Learn more

We respect the privacy and confidentiality of your protected health information (PHI). We are required by law to maintain the privacy of your PHI, including in electronic format. PHI is information that identifies you as an individual, such as your name and Social Security Number, as well as financial, health, and other information about you that is nonpublic, and that we obtain so we can provide you with insurance coverage. Providence Health Plan maintains policies that protect the confidentiality of personal information, including Social Security numbers, obtained from its members during the course of regular business functions. We must provide you with this notice and abide by the terms of this notice. This notice explains how we may use and disclose information about you in administering your benefits and it also informs you about your rights as our valued member. Finally, this notice provides you with information about exercising these rights.

Read our full Notice of Privacy Practice

Your member materials (member handbook and benefit summary) explain covered services, limits and exclusions.

• Access your member materials in myProvidence after creating a free account.
• Prefer a printed copy? Contact customer service.

Services considered investigational, not medically necessary, or cosmetic are not covered.

• Services may be reviewed on a case-by-case basis for medical necessity.
• See a list of non-covered services (PDF).

New technology policy; new application of existing technology coverage determination

New technologies and new applications of existing technologies are evaluated and approved for coverage when they provide a demonstrable benefit for a particular illness or disease; are scientifically proven to be safe and efficacious; and there is no equally effective or less costly alternative.

Emerging and innovative technologies are monitored by Providence Health Plan through review of trend reports from technology assessment bodies, government publications, medical journals and information provided by providers and professional societies.

A systematic process for evaluating a new technology or new application of an existing technology is proactively initiated when sufficient scientific information is available.

Plan-developed standards guide the evaluation process to assure appropriate coverage determinations. New technology must minimally meet the following guidelines to be approved for coverage:

• Technology must improve health outcomes. The beneficial effects must outweigh any harmful effects on health outcomes. It must improve the length or quality of life or ability to function.
• Technology must be as beneficial as any established alternative. It should improve the net health outcome as much, or more than, established alternatives.
• Application of technology must be appropriate, in keeping with good medical standards and useful outside of investigational settings.
• Technology must meet government approval to market by appropriate regulatory agency as applicable.
• Criteria must be supported with information provided by well-conducted investigations published in peer-reviewed journals. The scientific evidence must document conclusions that are based on established medical facts.
• Opinions and evaluations of professional organizations, panels or technology assessment bodies are evaluated based on the scientific quality of the supporting evidence.

Technology evaluation process

A core committee of Providence Health Plan medical directors and high-level physician specialists, practitioners and/or pharmacists evaluate and recommend coverage for new technologies. Their decisions are based on information provided by professional assessment and policy development organizations, as well as other medical experts.

Providence Health Plan prescription drug plans provide coverage for medications that are listed on the formulary* and are:

• Medically necessary for the treatment of a covered illness or injury
• Prescribed by a qualified practitioner for outpatient use
• Filled by an in-network pharmacy

*A formulary is a list of FDA-approved prescription preferred brand-name and generic drugs. Designed to offer drug treatment choices for covered medical conditions, it can help you and your provider choose effective, lower-cost options.

See the pharmacy resources page for more information and to view formularies.

The amount you owe for services is listed in your member materials which are available in myProvidence. Generally speaking, those amounts may be in the form of:

Coinsurance:

A percentage of the cost of a covered service. The provider will bill you for the amount due, if any.

Copay (also referred to as a copayment):

The fixed dollar amount you pay for a covered service at the time care is provided.

Deductible:

The amount you pay out-of-pocket before your plan starts paying for certain services.

Non-covered services:

Services not covered by your health plan.

Usual, customary and reasonable (UCR):

Out-of-network* providers do not have contracted rates. You are responsible for the difference between the health plan payment and the provider’s actual charge.

* Personal Option, Oregon Individual plans and Washington Individual plans do not offer out-of-network benefits.

Some services need approval before you get care.

• In-network providers typically handle prior authorization requests for you.
• Learn more about prior authorization.

• Age 18 is when it's time to move from pediatric to adult care. Use the Provider Directory to find in-network providers (including facilities and pharmacies): ProvidenceHealthPlan.com/findaprovider.
• Some benefits (like rehabilitation services) may have annual limits. If you reach a limit, we can help you find resources.
• Call Customer Service at 800-878-4445 (TTY: 711) for assistance.

• Get help in your language at no cost.
• Call Customer Service at 800-878-4445 (TTY: 711) for assistance.

Most providers will submit claims for you. If you need to file a claim:

• Visit ProvidenceHealthPlan.com/forms.
• Choose the appropriate form (medical, mental health, alternative care, vision, etc.).
• Follow the instructions on the form.

• In-network providers are listed in the provider directory.
• The directory includes provider contact information and other practitioner-provided information. Examples include: credentials, education, board certification(s), number of years in practice, languages spoken, and/or a short biography.
• Provider networks vary by plan. Search using your member ID number.

The provider directory includes in-network provider contact information in addition to other practitioner-provided information such as credentials, education, board certification(s), number of years in practice, languages spoken, and a short biography. Because provider networks vary by plan, search using your member ID number.

The following provides a general overview of how to access non-emergent care under different plan types. Please see your member materials, available in myProvidence, for plan-specific information about how to access primary care services specific to your plan.

Choice and Connect plans:

You must select a medical home (a designated primary care clinic in which a care team delivers patient-centered care focused on improving the health of the patient).

Personal Option, and Oregon and Washington Individual plans:

Services must be rendered by an in-network provider.

All other plans:

Referrals are not required. If your plan provides out-of-network benefits, you may choose to see an out-of-network provider; however, be aware plan coverage is typically lower for out-of-network care and you are responsible for the difference between the health plan payment and the provider’s actual charge.

The following provides a general overview of how to access specialty care, behavioral healthcare, and hospital services under general plan types. For information specific to your plan coverage, please refer to your member materials available in myProvidence. To access your member materials, log in at myProvidence, select “My Health Plan” in the top navigation, then select “Benefit Documents” from the drop down menu.

Choice and Connect plans:

• Most specialty, hospitalization, and behavioral health services require a referral from your PCP/medical home.
• No referral is needed for outpatient office visits for mental health or chemical dependency.
• Many preventive services do not require a referral.
• If your have vision or dental coverage, those services may be accessed without a referral.
• Some services require prior authorization. Your medical home will help with referrals and prior authorizations.

All other plans:

• Your PCP can refer you or you can self-refer to an in-network provider.
• Some services, including inpatient hospital services, require prior authorization (in-network providers arrange for any necessary prior authorizations).
• If your plan covers out-of-network care, you can self-refer, but your out-of-pocket costs may be higher.

Referrals to in-network specialists are not required

• Members with a Providence Medicare Advantage, Choice, or Connect plan need to select a primary care provider (PCP).
• Your PCP helps coordinate services and specialists.
• Don’t have a PCP? Find one: Provider Directory.

Questions? Call Customer Service at 503-574-7500 or 800-878-4445 (TTY: 711). You may also speak with your medical home.

Providence Health Plan offers a national network of providers. To locate an in-network provider, refer to the provider directory. Covered services rendered by out-of-network qualified providers nationwide are eligible for benefits at the out-of-network benefit level. [NOTE: Personal Option plans, Oregon Individual plans and Washington Individual plans do not offer out-of-network benefits.]

Emergency care for covered services is available worldwide for all plans.

Emergency services are provided both within and outside of the service area. If an emergency situation occurs, take immediate action and seek prompt medical care. Call 911 or go to the nearest emergency room.

You have options when your provider’s office is closed:

• Your PCP's office may have a physician on call for questions or guidance.
• ProvRN, a 24/7 care advice line, can help assess symptoms and suggest next steps.
• Immediate (non-emergency) care facilities treat non-life-threatening conditions that need attention right away. Examples include: Minor cuts or burns; ear, nose and throat infections; sprains or strains; headaches or dizziness.
• In an emergency, call 911 or go to the nearest emergency facility. Emergency care is most appropriate for accidents or sudden, unexpected injuries or illnesses that may result in serious medical complications, permanent disability or death if treatment is not sought immediately. Examples include: Severe chest pain, loss of consciousness, bleeding that doesn't stop, severe abdominal pain, sudden paralysis or slurred speech, etc.

Benefits for otherwise covered services obtained outside the Providence Health Plan service area vary by plan type; please refer to your member materials in myProvidence for information specific to your plan. To access your member materials, log in at myProvidence, select “My Health Plan” in the top navigation, then select “Benefit Documents” from the drop down menu.

In the event you have a complaint, please contact Providence Health Plan customer service. Representatives are available to provide information and assistance. For more information, please refer to the Problem Resolution section of your member handbook.

Get information about filing an appeal and external review (PDF)

Classification of Mental Health and Substance Use Disorder treatment and access standard

Mental health and Substance Use Disorder treatment services are characterized as specialty services when provided by behavioral and/or mental health professionals. This means that you must be able to access mental health or substance use disorder treatment services within 15 business days according to Washington law.

How an enrollee can find in-network mental health and substance use disorder treatment and services in their service area

You can find in-network providers by visiting our Provider Directory, available online at http://phppd.providence.org/ or calling Customer Service at 1-800-878-4445 to get information about a mental or behavioral health provider’s participation with Providence Health Plan and your benefits.

Steps an enrollee may take if they cannot access services in the required timelines

If you are having trouble making an appointment please call 1-800-878-4445 to speak with an intake specialist who will help you identify your needs and, if needed, facilitate an individualized appointment search.

How enrollees may file a complaint with WA OIC

If you would like to file a complaint with the Washington state Office of the Insurance Commissioner you may contact them at www.insurance.wa.gov or call 1-800-562-6900.

Resources for persons experiencing a mental health crisis

• Suicide Prevention Hotline
  The Suicide Prevention Hotline is 800-273-8255.
• Emergency Resources
  If this is an emergency or you think you may harm yourself, call 911.

Resources for Substance Use Disorders

• SAMHSA National Helpline
  1-800-622-4357
• Washington Recovery Helpline
  1-866-789-1511

Additional information regarding behavioral health services and resources are available to Providence Health Plan members. To access these resources, sign in to https://myprovidence.com. Information and resources are found on both the behavioral health resource page and under Health Topics.