POS FAQ
For LocalSelect Point-of-Service (POS) Plans
What Is Piedmont Community HealthCare?
Piedmont Community HealthCare, Inc., is a wholly owned subsidiary of Piedmont Community Health Plan, Inc. Piedmont Community HealthCare is a local company formed by the local medical community for local employers and their employees. Piedmont Community HealthCare offers network product options using Piedmont Community Health Plans network of participating physicians and hospitals. Our offices are located at 2512 Langhorne Road in Lynchburg. Members may call our customer service representatives at 1-800-400-PCHP (7247) or locally at 434-947-4463.
How does a Point of Service product work?
Basically, how and where you choose to receive your medical care determines your level of coverage and the cost of your medical care. You obtain the higher level of benefits at a lower cost when you receive medical care provided by or arranged through your primary care physician. This is called "in-plan," you receive "out-of-plan" benefits for covered services when you go directly to doctors without having your primary care physician arrange for the service. This is a lower level of benefits with a higher cost to you.
An exception is that female members receive two office visits each year to any participating OB/GYN physician or gynecologist without having to obtain a referral from the primary care physician. These services are covered at the in-plan level of benefits.
Will I receive a new insurance ID card?
Each employee and covered dependent enrolled with Piedmont will receive a Piedmont ID card. This ID card will include the employee's name, the covered person's name, the name of the primary care physician that was selected, a brief description of benefits, and Piedmont's telephone number and claims submission address. We encourage covered members to present their ID cards each time they receive services so that participating physicians will know what coverage the member has. Advantages that Piedmont offers include the following:
- Network providers file claims for members covered by Piedmont .
- Network providers accept the member's co-payment, coinsurance, or deductible in addition to the payment from Piedmont as payment in full and do not bill for amounts above the "usual and customary" and allowable charge.
- Coordination by your primary care physician of all medical care.
Employees or covered dependents needing services prior to receiving their ID card should let the physician's office, pharmacy, or other provider know that they are covered by Piedmont as of the group's effective date. We welcome calls from the employee, covered dependent, physician's office, pharmacy, or other participating providers if there are questions regarding eligibility and covered benefits. We can be reached at 434-947-4463.
What if I am traveling outside of the Lynchburg area and I need health care services? What do I have to do in order to receive in-plan benefits for the medical care that I receive while I am out of town?
We recognize that covered employees and their families are going to be traveling outside of the Lynchburg area for work assignments, for family vacations or to visit family. Covered members who are out of town and who need emergency care or urgent care services should seek care from the nearest medical facility. Although we know that it is not always possible to contact the primary care physician when services are needed while traveling outside of the Lynchburg area, we encourage members who can do so to contact their primary care physician before receiving services. Covered Piedmont members who need emergency care or urgent care services while outside of the Lynchburg area will receive coverage for these services as if they were in the Lynchburg area and had received these services with a referral from their primary care physician.
We ask that members who receive services for emergency care or urgent care while outside of the Lynchburg area call Piedmont at the medical management telephone number on their ID card within two business days of receiving services so that we can make arrangements in the claim system to have the claim for services received processed under in-plan benefits and can help arrange any necessary follow-up care that the member may need. Members who fail to notify us likely will have their claims paid at a lower out-of-plan benefit level since we will have no way of knowing that the services received were as a result of an emergency or urgent situation. However, members in this case may contact us and request that the claim be reprocessed under in-plan benefits by supplying information documenting that the services received were for emergency care or urgent care. Routine care, follow-up care, and elective care received while outside of the Lynchburg area will not be covered under in-plan benefits. No advance referral is needed from the primary care physician for emergency care or urgent care received while outside of the Lynchburg area.
What is the difference between emergency care, urgent care and routine care?
Emergency care means care received as a result of a bodily injury or serious illness, which threatens loss of life, limb, or senses and requires the member to seek immediate medical attention. Emergencies include heart attacks, hemorrhaging, poisonings, loss of consciousness, and convulsions.
Urgent care means care received for a health problem usually marked by the rapid onset of persistent or unusual discomfort associated with an illness or injury. These problems may include high fever, vomiting, sprains, and minor cuts. When in the Lynchburg area, urgent care situations can be handled by contacting the primary care physician, regardless of the time of day or day of the week. When outside of the Lynchburg area, members with urgent care situations may contact their primary care physician or seek care from the nearest available provider and contact Piedmont afterwards.
Routine care includes elective services and any other services that are for conditions that are not for emergency care or urgent care. Examples include office visits for consultations or for basic health services (such as treatment for chronic high blood pressure or routine gynecological care), any follow-up care necessary after receiving services for a medical emergency or urgent care situation, and ongoing conditions such as allergy shots or treatment of arthritis.
Will I need a primary care physician's referral for my annual check-up and Pap test with an OB/GYN physician?
Female members may receive up to two office visits each year to any participating OB/GYN physician or gynecologist under the in-plan benefits without first receiving a referral from the member's primary care physician. If more than two visits are needed to the OB/GYN physician's office or if services are needed outside of the OB/GYN physician's office or if a referral is needed to another specialist physician, then a referral will be needed from the primary care physician for such services.
How are referrals to a physical therapist or chiropractor handled?
All visits to a physical therapist or chiropractor must receive a referral from the primary care physician. We will work directly with the primary care physician, the physical therapist or chiropractor, and the member when the member needs these services. The referral process for each member is considered individually.
Do I need a referral for hospital inpatient services?
In order to receive in-plan benefits for covered inpatient services, the member must first receive authorization from the primary care physician and Piedmont. Inpatient services received without authorization or from nonparticipating hospitals are considered out-of-plan.
