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Members
Welcome!
Your medical plan includes an option called a
Preferred Provider Organization or PPO. The PPO is a network of hospitals,
physicians, and other health care providers who work with you and your health
plan to provide quality health care that is affordable to you. Your PPO
is operated by Managed HealthCare Northwest, Inc. (MHN). Your PPO is one
of two networks operated by MHN, either CareMark PPO or MHN PPO. In most
cases, your I.D. card includes the name of the PPO that covers you. Find
out the name of the PPO that covers you and remind your PPO provider of that
name (either CareMark PPO or MHN PPO) each time you receive care from a PPO
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It's Your Choice
Most health plans give you the freedom to choose any physician or hospital
at any time when you need care. You may choose to see a PPO provider and,
in most cases, receive higher insurance coverage, or you may see a provider that
is not part of the PPO network and receive your health plan's standard benefit
coverage. You make the choice each time you receive medical care covered
by your health plan. Please read your health plan benefit booklet to find out if there
are other requirements for you to receive higher insurance coverage, such as the
requirement that you select a primary care physician "gatekeeper" to manage all
referrals to specialist physicians for you. This is a requirement of
some, but not all, health plans. Please feel free to review this sheet for
"Tips on
Choosing a PCP".
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Your Health Plan I.D. Card
Your health plan identification (I.D.) card is your key to affordable,
convenient medical care. Your I.D. card identifies you as a PPO member and
opens the door to special privileges when you present it to the PPO physicians,
hospitals, and other health care providers listed in the directory.
Always present your I.D. card when you receive health care services.
When you show your I.D. card to PPO providers, they have agreed to extend the
following privileges and benefits to you:
- Bill your health plan for you. You do not
have to bill insurance.
- Waive any deposit in advance for services.
Co-payment amounts listed on your I.D. card should be paid at the time of
service. Otherwise, you will be billed for what you owe after your
health plan has processed your claim and paid your doctor or hospital.
- Notify the PPO or your health plan of all upcoming
hospital stays and emergency admissions for you, if pre-certification is
required by your plan.
- Accept the PPO fee as payment in full for covered
services (after your deductible or co-payment, if any). The resulting
savings mean lower out-of-pocket costs for you.
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In Case of Hospitalization
If you require hospitalization, remember to
inform your physician that you are a PPO patient. Ask to be admitted to
one of the PPO hospitals listed in this directory. In most instances, your
health plan pays higher benefits when you receive care in a PPO hospital.
Some health plans require that you receive authorization in advance of any
hospitalization and/or out-patient surgery and/or mental health treatment. The benefit booklet and
identification card you receive from your health plan will advise you if
MHN must be notified when your doctor proposes hospitalization, when you are
admitted to the hospital for an emergency, or for any other reason. When
this is the case, MHN's medical staff reviews your proposed treatment to make
sure that it is medically necessary.
When you choose a PPO provider, simply present your I.D. card and the provider
will take care of the notification for you.
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Is the Medical Service Covered?
MHN is not your insurance company. Contact the insurer or
administrator named on your
I.D. card or your employer for information on what services are covered, the
benefits provided by your health plan and your eligibility for coverage.
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Status of PPO Providers
The inclusion of a provider in the directory is not a guarantee of
participation in the CareMark or MHN PPO networks. Additions, deletions,
and changes may occur at any time. If you have a question about the status
of any provider, whether listed in the directory or not, call MHN's Provider
Relations Department for confirmation.
MHN Provider Relations Department
(503) 413-5800
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Board
Certification
Most PPO physicians are board certified. Board certified physicians
have passed an examination and have met certain other criteria in their medical
specialties or subspecialties. If you want to know whether a PPO physician
has board certification, please call the physician's office.
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Service Area
The CareMark PPO and the MHN PPO service area includes the counties of
Multnomah, Washington, Clackamas, Columbia, Wasco, Hood River, Yamhill, Lane,
Clatsop and Coos in the State of Oregon and Clark, Cowlitz and Skamania in the State of Washington.
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We're Here to Help
At MHN, we want to make sure you receive the full medical benefits you are
entitled to and that your PPO providers are delivering all of the services to
you which we have promised. If you have any questions, please feel free to
call us.
We encourage you to select a primary care physician for yourself and each member
of your family whether this is a requirement of your health plan, or not.
Primary care physicians, which include physicians in family practice, general
practice, internal medicine, pediatrics, and certain women's health care
providers are
listed in the directory. If you need help in selecting a physician, call
us and we can help you select PPO physicians best suited to meet your needs.
When you need to notify MHN of hospitalization or want to talk to us for any
reason, call us. We're here to help.
CareMark PPO
and
MHN PPO
(503) 413-5800
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