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What is covered by the $25 co-pay?
More and more medical procedures, especially surgery, are being performed as an out-patient, either in hospitals, medical and surgical centers or even in a physician's office. It saves money when patient's are not admitted to hospitals as in-patients. Many of these procedures are highly intricate and, when done in a doctor's office, obviously cannot be classified as run-of-the-mill office visits. "Other Services," as these treatments are called by managed care plans, are not covered by the $25 co-pay (with which there is no deductible) that is paid for in-network office visits. In addition, there are other treatments, such as antibiotic and cortisone shots, which are not complicated, but are also classified as "Other Services."
How do we know if the procedure a doctor performs is considered surgery?
Any procedure code which begins with 1, 2, 3 (except 36415), 4, 5, 6 or 9 is considered a surgical procedure. If you are unsure if your procedure is considered surgery, ask your physician or the attending nurse. Some examples of unsuspecting surgical procedures are setting a broken bone and removal of a wart or mole.
Lab work and x-rays your physician orders in conjunction with an office visit, even when performed outside the network doctor's office (but not in a hospital), are covered by the $25 co-pay and paid at 100% with no deductible. Routine mammograms, pap smears and prostate exams are also paid at 100% after a $25 co-pay, if provided by a PPO doctor. Routine physicals are not covered at all. Routine tests (i.e. blood tests, etc.) done in conjunction with a routine physical are not covered, unless your PPO physician has a medical reason for ordering them.
Is my doctor in the PPO network?
If you are covered by one of the numerous Preferred Provider Organization (PPO) networks used by CP participants, you should have received a directory that includes doctors, hospitals, and ancillary providers that participated in the network in your area at the date the directory was printed. New providers may have since been added or some may no longer take part, making the directory incomplete. Regardless, it is always a good idea to check the provider's status; sometimes, it is simply easier or desirable to call the provider's office.
Unfortunately, some enrollees have been burned by inquiring in that manner, because UniCare has other types of health insurance plans, such as the indemnity plan that some CP employees utilize. The office help with whom you talk may or may not understand the differences in plans.
If you are enrolled in one of UniCare's PPO plans, then the proper question to ask providers is whether or not his or her office participates in the regional PPO with which UniCare has a contract.
For example: in Kentucky, one should ask:
In West Tennessee, ask:
In Dallas/Fort Worth and Denton, TX area, CP insureds should inquire:
Can I use a PPO provider if I am out-of-town?
Yes, if you follow reciprocity procedures. You will need to call the toll free number on your medical ID card to obtain the name of physicians in the area. Only by making this phone call can you receive PPO benefits outside of your network area. Reciprocity is intended for use by participants when traveling. College students can be assigned to the PPO at the location of his/her college.
Does my PPO have a website?
Some internet addresses of the PPO networks that are part of the CP Plan are available. Provider directories, maps and other important facts are on-line for those who prefer the web to hard copies. Some information may be found at these sites that is otherwise unavailable.
HOME BENEFITS INSURANCE For more information, contact Robert Heflin
Page updated on April 6, 2004 Information updated on March 25, 2003 Pages maintained by Elinor Swindle Brown 
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