Frequently Asked Questions

Where you receive care can greatly impact how much you will pay for healthcare services. By using an in-network provider, you will maximize your insurance coverage while keeping costly out-of-network expenses at bay. 

Yes, you can use the Treatment Cost Estimator tool located in your member account. This tool allows you to estimate both total costs and out-of-pocket expenses for common medical treatments and services, helping you find care that fits within your budget.

When using an in-network provider, certain preventive services are covered at no cost sharing to you. Use our Preventive Services tool located in your member account to see a full list of what is available to you.

In order to determine the feasibility of coverage for special employment situations, the following steps will apply:

1. Contact your Account Manager
2. Provide the details of the situation.
3. Upon Underwriting approval, your Account Manager will work with you to determine the most appropriate network for the employee.

Physicians Health Plan provides "out of network" benefits for members enrolled in point of service benefit plans. With out of network benefits, members may use doctors and other health care providers outside of the PHP network. Payment rendered by PHP will be based on language in the member’s certificate of coverage that in most cases requires the amount to be either:

The In-Network Provider's standard rate adjusted by a geographical factor assigned to the location where the service was rendered; or

The out of network Provider's eligible billed charge.

PHP utilizes geographical factors established and used by the Centers for Medicare and Medicaid Services (CMS).

By using In Network provider rates and geographical factors, the maximum payment PHP allows for out of network claims will, at times, be less than the amount billed by a provider for a particular service. This may affect the member's out of pocket costs because the member is responsible for the difference between the out of network provider's charge and what PHP pays. This is known as Reasonable and Customary.

A referral to a non-participating doctor may be obtained if a uniquely specialized procedure is medically necessary and not performed by any participating doctors. This process must be requested by your participating doctor and approved by PHP, in writing, prior to receiving the services.

Our provider directory helps you to find a doctor or a facility in your network. Please be aware that this information is updated on a regular basis. To be certain a doctor is participating, ask the office staff prior to receiving care, or call the PHP Customer Service Department. Always show your ID card at each visit.