Frequently Asked Questions
- How do I contact the NHealth Care Coordination Team?
A care coordinator can be contacted by phone, email, or fax.
Phone: (405) 515-6746
Fax: (405) 447-3850
- Why do I need to designate a Primary Care Provider (PCP), and can it be a mid-level provider?
Having a PCP is important to establish and maintain a working relationship with your PCP and to help members manage their health and make decisions about their healthcare needs. A PCP will also help you maintain overall health and better coordinate total medical care and navigation through the healthcare system.
Yes, you may see a mid-level provider if their supervising physician is an NHealth provider.
- Can I change PCP’s during the benefit plan year?
Yes, you may change to any NHealth PCP at any point during the benefit year. If you choose to change PCP's you will need to resubmit the PCP assignment form.
- Do I need a Primary Care Physician (PCP) referral to see a specialist?
No, you may see any doctor within NHealth without a referral.
- When is a referral required?
A referral is only required when a service is needed outside of the NHealth network. Authorization will only be given for those services which are truly not available in the NHealth network. Authorization is not granted based on convenience.
Without prior authorization, you are fully responsible for all costs. Additionally, there are not any benefits paid (except meeting the definition of a true emergency) for services provided out of network.
- How do I find an acceptable out of network provider?
A Care Coordinator will assist you in finding a provider if services are needed outside of the NHealth network. The Care Coordinator will search the upper level network tiers in this order:
- IHP (Integris Health Partners)
- OHN (Oklahoma Health Network)
- PHCS MultiPlan
The Care Coordinator will then supply a list of potential providers, who fulfill the services needed, and the member will choose which provider they want to schedule with.
- What will NHealth Care Coordinator authorizations cover?
Only services that cannot be provided at the NHealth network level. Authorization may be made for a particular doctor, a specific service, or a particular specialty. However, ancillary diagnostic testing will not be authorized merely out of convenience while seeing an NHealth network provider. Rather, in most all circumstances, any diagnostic testing and laboratory testing will be required to be performed at NRHS facilities.
- Who approves the referral request?
An Oklahoma (Registered Nurse) RN Care Coordinator will review the request and approve for pre-defined cases. The medical director will grant overall approval and approval for the more complex cases.
- If a referral request is approved, how long is it good for?
A referral request will be approved by either a designated time frame, or by number of visits depending on what service is needed. Once the designated time frame or number of visits has expired, a new referral request will need to be submitted.
- If the authorization is approved, how is the claim process?
As if the services were being provided in network at the NHealth level.
- How long will it take to get the authorization approved for a request to see someone at a higher network level?
Each case is different, and it depends on whether or not the request is pre-defined or if it must be considered by the medical director. The goal for the majority of cases is to have approval in 1-2 business days. More complex cases may take longer for review.
- What if we need non-emergency urgent care out of state?
Unfortunately, the Coordinated Care Plan does not offer any benefits for out of state non-emergency services, and the NHealth Care Coordinator would not be able to authorize such, because there are network providers capable of offering the service. However in highly specialized circumstances, if the member’s PCP recommended urgent care while the member is out of state, the member may contact the Care Coordination office for further assistance. This option is only available via recommendation of the member’s PCP.
- Does the Coordinated Care plan cover urgent care services within the state of Oklahoma?
Yes, the plan currently allows for members on the Coordinated Care Plan to use an OHN urgent care in addition to NHealth urgent care facilities without a referral. There are currently 3 urgent care facilities included in the NHealth network and are the preferred facilities to use. Please see the resources section to identify specific locations.
- If I have a true life threatening emergency and am seen by a non-network provider(s), how is the claim paid and who decided if it is truly an emergency?
The "allowable" charges for a true emergency are processed as if in network, but the patient remains subject to balance billing by the provider. The determination of what is a true emergency is covered by laws such as the Affordable Care Act and EMTALA, and the plan document itself.
- If I have one of the covered diseases eligible for rebates, and am fully compliant with the requests of the NHealth Care Coordinator, what must I do to get my rebates?
Nothing, they will be processed automatically each quarter based on claims that have been submitted to the third-party administrator for processing. Rebate checks will be sent directly to the member on a quarterly basis.
- Can I be eligible to receive rebates for more than 1 disease process?
Yes, you can be eligible for rebates for co pays and pharmacy expense associated with one or more of the five designated chronic disease states. Diagnoses not included in the five designated chronic disease states are not eligible for rebates.
- What is in included in being “compliant” to be eligible for rebates?
Each case will be individually geared towards chronic condition being monitored and may vary slightly from member to member. Generally it will be very achievable goals. Specifics included for every member will include: keeping all scheduled doctor’s appointments, medication compliance, completing scheduled lab testing, and communication with the care coordination team.