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The UVA Health Plan’s Third Party Administrator, Southern Health, has a provider network -- a designated contracted group of participating health care providers within a geographic area, from whom you and members on your policy, can seek health services and receive “In- Network” benefits. When you receive care outside of the participating provider network area, some of the rules and costs change. Sometimes these changes can have a big impact, so it’s important to understand how they work in advance.
What You Need to Do
If you want to seek care from a physician located outside of the Southern Health network, (for example, a physician from a center of excellence like Cornell or Johns Hopkins), you need to ask your participating network physician to submit a pre-service request for prior authorization at “In Network benefits” to Southern Health. Authorization at “In-Network” rates is only granted when Southern Health determines that there are no providers in the Southern Health network able to perform the service. THIS IS TRUE EVEN IF YOUR PARTICIPATING DOCTOR REFERS YOU “OUT-OF-NETWORK”. If the authorization is not granted by Southern Health with “In-Network” benefits, the authorization may be granted with “Out-Of-Network” benefits which can be extremely expensive to the member. So read your authorization letter very carefully and ask the UVa Health Plan Ombudsman for clarification or assistance. Get the authorization information directly from Southern Health –do not rely on translated benefits from your doctor office/hospital.
Be attentive to the limits and type of the authorization you receive and be sure any follow up care and additional procedures/tests are also pre-authorized.
Important Note About Costs
Out-Of-Network payments by Southern Health can be a small percentage of the actual provider charges and also can be limited, such as the current $2,955.00 per day capped allowable rate for inpatient admissions. Out-Of-Network outpatient allowable amounts paid by Southern Health are currently capped at 105% of the Virginia Medicare rate. You will be responsible for not only a deductible and 25% (or 40% if Low Premium) co-insurance of the allowable amount, and often a very large “amount above the allowable”.
If you are considering receiving medical services from an Out-Of-Network provider for a non-emergency, it is advisable to thoroughly research your potential costs before making your final decision. The Southern Health Customer Service toll-free line at 888.975.9557 is one resource. It is also perfectly reasonable to ask your Out-Of-Network provider to send you a pre-service estimate of the costs and procedure codes, assuming there are no complications. You should then compare the estimated costs from each provider to the Southern Health allowable rates for your specific procedure codes.
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