Frequently Asked Questions
We understand you may have questions, and we’re here to help. Below you’ll find answers to the most common topics we’re asked about. If you need further clarification, please don’t hesitate to give us a call at 800.318.1590.
Network Information
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Balance Billing means a provider is expecting you to pay a dollar amount ABOVE what your employer allows for the service. For example, if a doctor charges $1,000 for a procedure and the maximum amount allowed by the insurance is $800 you, the patient, could be billed the extra $200 because the insurance only pays $800 and doctor expected to receive $1000. IF you utilize a PVHCC provider you are GUARANTEED not to have to pay any amount above what the insurance allows. You will always be responsible for your deductible amount and your co-insurance amount but NOT responsible for amounts MORE than what the insurance says is "allowed". If you have any questions about this issue, feel free to contact the Cooperative office at 812-683-3332 or 800-318-1590, or you may send an email to pvcoop@pvcooperative.com.
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Indiana University Health Paoli Hospital - 642 West Hospital Road, Paoli, IN 47454
800.999.4420——————
Daviess Community Hospital - PO Box 760, 1314 E. Walnut Street, Washington, IN 47501-2198
812.254.2760——————
Deaconess Memorial Medical Center - 800 West 9th Street, Jasper, IN 47546
812.996.2345——————
Perry County Memorial Hospital - 8885 State Road 237, Tell City, IN 47586
812-547-7011——————
Saint Charles Surgical Pavilion - 1900 Saint Charles Street, Jasper, IN 47546
812.634.1211——————
Saint Thomas Outpatient Surgery Center - 600 W 13th Street, Jasper, IN 47546
812.482.7441
Pre-Certification
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A pre-certification is an approval that you receive for a procedure that is deemed medically necessary BEFORE the procedure is done.
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The procedures that require pre-certification vary with each employer’s health care plan. If you are uncertain about the need to pre-certify, call the Cooperative for verification.
IF IN DOUBT OR YOU HAVE ANY QUESTIONS, PLEASE CALL TO VERIFY IF YOU NEED A PRE-CERTIFICATION OR NOT.
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Ask your doctor’s office for the CPT code of the procedure/test/surgery that you will be having. Call the number on the back of your card. You will be asked for basic information such as name, date of birth, id number, group number, etc AND THE CPT CODE FOR THE PROCEDURE. DO NOT ASSUME THAT THE DOCTOR’S OFFICE WILL CALL FOR YOU!
The third-party administrator will determine if a pre-certification is necessary. If so they will send you to the appropriate UR Company to begin the process. After taking the basic information, the Utilization Management Nurse will need medical information from your doctor to verify that the test/procedure is medically necessary and is being done in the most cost-effective setting.
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Once all of the medical information is obtained, it will take 1 working day or less to complete the pre-certification process. In many instances, it takes only a few minutes.
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You will receive written notification, via US Mail, that the pre-certification has either been approved or denied. If you have not received that notification at least 2 days before your scheduled test/procedure, you should call the Cooperative.
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There may be financial penalties for either failure to pre-certify or for having a test/procedure done that has been denied. You will need to check with the employer that provides your insurance or with the TPA that processes the claims. The telephone number for your TPA should be on the back of your insurance card.
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You, a family member, or a friend should call the Cooperative as soon as reasonably possible, preferably within 48 hours of a hospital admission.
DO NOT ASSUME THE HOSPITAL WILL DO THIS FOR YOU!
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No, doctor's office visits do not require pre-certification, but you may need a referral.
Denial/Appeal
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A pre-certification denial is a decision that has been made to deny a doctor's request to perform a procedure. This decision is made by the Medical Director of the Cooperative.
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If pre-certification is denied your physician will be notified by telephone and you and your physician will receive notification letters in the mail. The notification letters will be sent within 24 hours of the decision to deny the pre-certification. The notification letters explain the exact reason for the denial. You should discuss the reason for the denial with your physician to decide whether or not you want to appeal or challenge the decision. If you decide to appeal, you or your physician must send a letter to the Cooperative that specifically states, "I want to appeal the pre-certification denial for (list the service(s) and why you want to appeal)." Appeals can be processed more quickly if they include as much medical information as possible specifically related to the reason for the denial. The Cooperative must receive the appeal within 180 days of the date on the notification letter you received. Once the appeal has been reviewed, you will receive written notification of the outcome of the appeal.
Pre-Certification Denials
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When you are in the hospital, the nurses at the Cooperative work with the nurses and doctors at the hospital to make sure you are receiving the care that you need. If you are in the hospital and the Cooperative Medical Director feels there is a more appropriate level of care for you, he will deny your admission or continued stay in the hospital.
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There are several reasons why some of the days you were in the hospital may be denied. They might include:
• The care you received could have been safely provided in another setting, such as outpatient, at home with home health, or in a skilled nursing facility
• There was a delay in receiving the test/procedure/surgery you needed and the delay was not for a medical reason
DENIAL PROCESS: If some hospital days are denied, the hospital will be notified by telephone and you and your physician will be sent notification letters within 24 hours of the determination of the denial. The notification letters state the exact reason for the denial. IF YOU WERE A PATIENT IN A NETWORK HOSPITAL, YOU ARE NOT FINANCIALLY RESPONSIBLE FOR THE DENIED DAYS. You should discuss the reasons for the denial with your physician to decide whether or not you wish to appeal. If you decide to appeal, you or your physician must send a letter to the Cooperative that specifically states, "I want to appeal the denial for (list the service(s) and why you want to appeal)______." Appeals can be processed more quickly if they include as much medical information as possible, specifically related to the reason for the denial. The Cooperative must receive the appeal within 180 days of the date on the notification letter you received. Once the appeal has been reviewed, you will receive written notification of the outcome of the appeal.
Continued Hospital Stay Denials
Referral
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Any time you are going to use a physician/facility that is not a Patoka Valley Health Care Cooperative network provider you need a written approval from the Cooperative.
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An approved referral from the Cooperative insures you get the negotiated discount, the bill is paid at your highest benefit, and protects you against balance billing.
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Balance billing is the practice of billing the patient for the difference between what the physician/facility charges for a test/procedure and what the insurance says is the maximum amount allowed. For example, if a physician charges $1000 for a procedure and the maximum amount allowed is $800, the patient would be billed for the $200 difference plus any amount remaining of the $800 not paid by the insurance.
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The physician who is referring you to an Out of Network provider must send a written referral request to the Cooperative. This form can be found on our website at www.pvcooperative.com/referrals. All Patoka Valley Health Care Cooperative providers have the form in their office. The referral form MUST be completed by the physician! REFERRALS MUST BE RENEWED ANNUALLY! The processing of a referral takes approximately 48-72 hours, therefore it is important to obtain referral as soon as possible to allow for ample processing time.
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You will receive written notification, via US Mail, that the referral has either been approved or denied. If you have not received that notification at least 2 days before your scheduled appointment, you should call the Cooperative.
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A referral denial is a decision that has been made to deny a doctor's request to send you outside the PHVCC network.
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There are several reasons why a referral request may be denied by the Cooperative. They may include:
• There are providers or a facility within the Patoka Valley Health Care Cooperative network that can provide the care.
• The physician/facility the patient is being referred to is not a provider in your wrap network.
DENIAL PROCESS: If a referral is denied, you and your physician will be sent notification letters within 24 hours of the determination of the denial. The notification letters state the exact reason for the denial. You should discuss the reasons for the denial with your physician to decide whether or not you wish to appeal. If you decide to appeal, you or your physician must send a letter to the Cooperative that specifically states, "I want to appeal the denial for (list the service(s) and why you want to appeal)." The appeal should specifically address the reason for the denial. You will receive written notification of the outcome of the appeal.
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If a referral is denied, the written notification will include the reason for the denial and the procedure for you to appeal the decision.
Emergencies
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In a true emergency, go to the nearest emergency room. Your health insurance will process the bill at the IN NETWORK benefit since you did not plan the emergency.