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 About MVPPO Dental PPO Sales Team  Search Our Web Site Search for a Provider Nominate a Provider Claim Status  Nationwide Coverage Client Service  Provider Directories PPO FAQ's Glossary Abbreviations Feedback HealthCare Links Back to Home |
A PPO (Preferred Provider
Organization) is a company which has developed a network
of quality hospitals, physicians, and other health care
providers. These providers have agreed to offer fee
reductions in return for patient referrals from the
network. PPOs offer their services to health insurance
companies, third party administrators (TPAs), and
self-insured companies. When you use physicians or
facilities in the network, your out-of-pocket expenses
are less than if you go outside the network. 2. What is a preferred provider? A preferred provider is any health
care professional or facility which has signed a contract
with a PPO to provide health care services to a PPO
member. PPO providers have met strict credentialing
criteria established by the PPO and have agreed to abide
by the terms of the PPO provider agreement. Only after
they meet these requirements are providers allowed to
become a part of MVPPO or its affiliates. Choose a physician, hospital or
other health care facility and make an appointment. Be
sure to tell the provider that you are a member of the
network listed on your benefit card. Your benefit card
should also have the insurance company or third party
administrator listed on it. In most cases, the provider
will file the claim for you. Your insurance company will
send you an Explanation of Benefits at a later date. 4. Can I use a physician or facility not listed in the MVPPO provider directory? Yes, but remember, your expenses
will be less if the provider is a participating member of
the MVPPO network. This is the advantage of a PPO. Follow
your employer's benefit plan requirements. Both PPOs and HMOs are managed care
plans meaning that they manage the cost of your health
plan while still providing quality care. A PPO allows you
freedom of choice to still use non-network providers. You
will likely pay more for non-network providers, but you
will probably still have benefits for covered services.
With most HMOs, if you go outside the network, you
usually pay the full cost of the service. 6. Why do I have more than one PPO network listed on my card? I thought MVPPO was my PPO. MVPPO is your PPO. In some states
we have direct contracts with physicians and hospitals,
while in other states we have indirect arrangements with
providers by contracting with another PPO. If you see a
name other than MVPPO, it means MVPPO is
"partnering" with another PPO in that area.
Since the provider has a direct contract with that
partner PPO, it is necessary to have them listed on your
ID card along with MVPPO. 7. My provider says he/she has never heard of MVPPO. This is probably an instance where
we have a "partner" arrangement with another
PPO and the provider hasn't been notified of the
arrangement. Just be sure to ask the provider if they are
a member of the "partner" PPO. The provider can
be directed to call MVPPO if they wish to verify that MVPPO
has a contract arrangement with the "partner"
PPO. 8. I have called MVPPO to check whether my doctor is a PPO provider. If MVPPO tells me he/she is, why do I have to check with the provider when I call for an appointment? Almost all providers who are listed
in the directory or given as a referral over the
telephone are active providers in MVPPO. However, if a
provider has terminated their participation in the PPO,
there is often a lag in the time it takes to put that
information into MVPPO's computer files. This lag can be
anywhere from a few days up to 2-3 months depending upon
how promptly the provider notifies us. Therefore, it is
very important that you ask the provider if they
participate in MVPPO and/or the "partner"
network. 9. I asked to have my doctor added to the network and he/she is not yet a member. Why not? Several possible reasons are listed below:
10. How can I speed up the process of having my doctor added to the network? Ask your provider if he/she would
be willing to review some material regarding the PPO.
Fill out, or better yet, have the provider complete a
Provider Request form, then mail or fax it to our office.
11. What benefits will I get if I use the PPO providers? Your plan design (benefits and
coverage) is determined by your insurer. Some have plan
designs which pay a larger portion of the bill if you use
a PPO provider, which reduces the amount you may pay out
of pocket. An example is given below using a benefits
schedule which pays 90% if you use a PPO provider, and
80% if you use another provider. The PPO provider gives a
20% discount. Some plans have a flat fee (co-pay) you pay
to the PPO provider at the time of service. In this case,
if you use a non-PPO provider, you may be responsible for
a percentage of the total billed amount, as well as
having a deductible to meet. 12. Is MVPPO my insurance company? No. MVPPO is the PPO network only.
It is a program that works in correlation with your
employer's healthcare coverage. MVPPO does not insure
lives, does not pay claims, and does not determine
benefit coverage. MVPPO offers you a high-quality network
of health care providers at a negotiated rate. 13. Does my provider call your toll-free number to verify benefits, eligibility, or to precertify a hospital stay? No. There should be another
telephone number (or perhaps two) listed on your ID card
for these services. MVPPO does not provide these
services. 14. Who do I call to check if my claim has been paid? Call your claims administrator or
insurance company as listed on your ID card. 15. I have a dental plan. Is MVPPO my PPO for dental also? Are prescriptions covered under my plan? Where do I get a listing of the pharmacies? Check your dental insurance card or
your prescription card. MVPPO offers a dental PPO, however,
you may have coverage through other various PPOs. 16. Can I use another doctor in the same group as the one I was referred to? It is still necessary to check with
the group's billing personnel and ask if the other doctor
also participates in the PPO. Each doctor has to go
through a separate contracting procedure, so he/she may
not be in the network. 17. Do I have to pay the doctor up front? If there is a co-pay for PPO
physicians listed on your card, you only have to pay that
amount. If there is not, we ask that doctors wait until
the claims have had the PPO discounts applied, then bill
patients for their portion. The doctors are not obligated
to do this and may require payment in full up front
unless a co-pay is involved. The provider should then
refund any discount to you. 18. What do I do if I need a specialist and there is not one listed? Call MVPPO. We can check our
database or, if necessary, check with the individual
leased networks and get the most up-to-date listing of
specialists in your area. If there are none available,
call the telephone number you have for benefits
information and ask what you should do. 19. What do I do if I have a concern, compliment or comment about one of the providers? Please put it in writing, be specific, and include:
Click here to send
your comments via e-mail or send snail mail to: 7083 Grand National Drive Suite 104 Orlando, Florida 32819
20. In simple terms, how can I use the PPO effectively with the fewest headaches?
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