Frequently Asked Questions

What is a PPO?
How do I know if my doctor or hospital participates with my PPO?
If you want a specific physician added to your network, who should you contact? 
When do I need to pre-certify and how?
What is case management?
What is COBRA?
Will I be able to continue coverage when I terminate employment?
What events consitute a COBRA qualifing event?
What is HIPAA?
What is Creditable Coverage?
What is an Explanation of Benefits (EOB)?

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Q. What is a PPO?

A.  PPO stands for Preferred Provider Organization. A PPO is a network of medical providers who are contracted to provide quality services to patient at discounted pricing. The plan and the patient save money when participating providers are used. PPO providers include physicians, hospitals, outpatient facilities as well as many other ancillary providers.

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Q. How do I know if my doctor or hospital participates with my PPO?

A.  The PPO will either provide a printed PPO directory of participating providers or provide a website with the most current information. Additionally the PPO has a toll free number to call and verify if a provider participates. You may also contact Fox/Everett's customer service at the number on your ID card to verify if a specific provider participates with your PPO.Note: It is recommended that you check the status of your doctor or hospital participation in your PPO prior to scheduling appointments or hospital admissions for medical care.

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Q. If you want a specific physician added to your network, who should you contact?

A.  You can request your physician contact the PPO network listed on your medical identification card, you can contact the PPO and request that they contact your physician or you can contact Fox/Everett's customer service and ask that we contact your PPO.

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Q. When do I need to pre-certify and how is it done?

A.  It is your responsibility to contact the pre-certification carrier or to have a family member or your provider contact them. All inpatient hospital admissions must be pre-certified. Additionally some plans require specific out-patient services to be pre-certified; please check your Summary Plan Description to verify what your plan requires or contact Fox/Everett's customer service to verify when pre-certification is required. Note: Failure to pre-certify admissions or outpatient services can result in a reduction of benefits.

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Q. What is case management?

A.  Case management is the management of any medical episode that is or could potentially be a large dollar claim. Case managers assist with the discharge planning upon your discharge from a hospital. They assist with arranging home health care, durable medical equipment and other services you may require upon discharge. Case managers also work to insure you are receiving the correct level of care at all stages of your illness. They will negotiate discounts with specialty providers, arrange air transportation when required and in general be your care counselor. Always cooperate with case managers as your best interest is always at the forefront of their services.

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Q. What is COBRA?

A.  The Consolidated Omnibus Budget Resolution Act (COBRA) provides for continuation of your current group benefits should you experience a loss of coverage due to a "qualifying event" such as loss of your employment, reduction in hours, divorce and students reaching plan age limits.

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Q. When my employment terminates, will I be able to continue my insurance coverage?

A.  Yes, if you elect to continue coverage by completing the COBRA Election Form or Coverage Continuation Form and paying the required premium. COBRA and coverage continuation premiums are almost always higher than the contribution you make for your coverage as an active eligible participant.

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Q. What events constitute a COBRA qualifying event?

A.  The qualifying events with respect to an employee, spouse or dependent who is a qualified beneficiary are:     

  • Termination of employment (for reasons other than the employee's gross misconduct); and     
  • Reduction in the employee's hours of employment with respect to an employee's spouse or dependent child who is a qualified beneficiary    
  • Death of the employee    
  • Divorce or legal separation from the covered employee    
  • The employee's entitlement to Medicare    
  • The child's ceasing to be a covered dependent child under the terms of the plan     
  • The employer's commencement of a bankruptcy proceeding under Title 11 of the United States Code

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Q. What is HIPAA?

A.  HIPPA stands for Health Insurance Portability and Accountability Act.  An important provision of HIPAA is to improve the portability and continuity of health coverage provided in connection with employment    

  • HIPAA limits the length of pre-existing condition exclusions that can keep you and/or your dependents from getting full coverage    
  • HIPAA generally prohibits the health plan from denying coverage or charging higher rates based on your dependents' current health or health history     
  • HIPAA may give you a special enrollment period for enrolling in the group health plan when you lose other coverage if you chose not to join the health plan when you are first eligible or when you have a new dependent

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Q. What is Creditable Coverage?

A.  Creditable Coverage is the beginning and end dates you and/or your covered dependents were covered by a qualifying health plan. In order to go onto another plan without being subject to the pre-existing limitations, you must have been continuously covered by another plan and not have had more than a sixty-three (63) day break in coverage. Upon termination of your coverage with your current plan, you will be issued a "Certificate of Creditable Coverage" and you will need to give a copy of this certification to your new employer.

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Q. What is an Explanation of Benefits (EOB)?

A.  The Explanation of Benefits (EOB) is an explanation of how your claim was processed. It will include the total charge submitted by the Provider and will identify any ineligible charges, discounts, amounts applied to the deductible and the patient responsibility. Any amounts shown as "patient responsibility" should be paid directly to the physician, hospital or other service provider. 

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