Yes. You should have your doctor pre-certify inpatient hospital stays, skilled nursing stays, rehabilitative therapy, mental health services, home health services, durable medical equipment, oxygen equipment and hearing aids.
If you are planning to have elective surgery, the following should be pre-certified: Organ transplants, intestinal or gastric bypass for obesity, cerebellar and dorsal stimulator implants, insertion of a prosthesis for cleft palate, plastic surgery including mammoplasty, and reduction mammoplasty.
Your medical provider should call 1-800-292-2288 to pre-certify services.
The Funds has a Directory of Cooperating Providers that you should use for all medical services. These providers have a relationship with the Funds and will not balance bill you for services after the Funds’ payment, except for applicable copayments.
You may go to providers outside the Funds’ Cooperating Provider Directory, but those providers may attempt to balance bill you for amounts in excess of the Funds’ payments. When this happens, the Funds will protect you from paying these amounts, but keep in mind that the providers may indicate an unpaid balance on your credit report.
The Funds also has a directory of Durable Medical Equipment (DME) and Hearing Aid providers that must be used for obtaining those services. Services from non-cooperating DME and Hearing Aid providers are not covered. If you are currently using items being supplied by a DME company not in the Funds’ DME Directory, you will need to switch to one of our Cooperating DME vendors.
*Note – If you are in the Funds’ 1993 Benefit Plan, there is a small listing of Non-PPL providers. If you have services from these providers you will incur a higher co-payment responsibility.
The Funds maintains a database of “Cooperating Providers” that have agreed to not balance bill you. While you are not required to use the providers in this database, these providers have agreed to accept the Funds’ payment as payment in full, less any applicable copayment you may owe.
Beneficiaries who live in southwest Pennsylvania, northern West Virginia and Birmingham, Alabama, may elect to enroll with a PCP. Contact the Fund’s Call Center (800-291-1425) to inquire about a PCP in your area.
There are several factors that need to be considered to make that determination. Please call the Call Center (800-291-1425, option 2) to provide information about your other insurance. The Funds will also periodically ask you to submit updated information about your other insurance coverage.
That is your decision to make. If you decide to terminate your other coverage you will need to mail the Funds a copy of the termination letter from your other insurance plan to:
Funds Health Call Center
160 Heartland Dr.
Beckley, WV 25802
If you keep your other insurance, please call the Call Center (800-291-1425, option 2) to provide information about your other insurance. The Funds will also periodically ask you to submit updated information about your other insurance coverage.
No, the Funds is your Medicare Part B payer for non-facility providers. When you go to a physician or other non-hospital type of provider (i.e. radiologist or laboratory, etc.) you should present only your Funds ID card to those providers because the Funds is your Medicare Part B payer. If you go to a hospital, a skilled nursing facility, or have home health care, these providers must bill Medicare Part A for all services and then bill the Funds’ plan as the secondary payer.
If you are Medicare eligible, and have signed up to have the Funds as your Medicare Part B payer and Medicare confirms that transition, your doctors will be required to bill the Funds for all Medicare Part B services, except those furnished by non-facility providers (e.g. hospitals, skilled nursing facilities, home health agencies, etc). Until it is confirmed that you are in the Fund’s Medicare Part B plan, your doctors should continue to bill Medicare Part B for all services. Your doctor can contact our Provider Services department at (888) 865-5290, if they have any questions.
No, the Funds does not recommend that you enroll in a Medicare Advantage plan. The Funds plan is your Medicare Part B plan and will pay your doctors’ bills and other non-hospital charges. You will need to present your Funds’ health card to your doctor the next time you go to his office. Medicare Part A will pay your hospital bills, just present your Medicare card to the hospital at the time of service.
Yes. Hearing aids must, however, be ordered through one of the Funds’ Cooperating Hearing Aid vendors and must be approved by the Funds’ Prior Authorization Department (800-292-2288).
A hearing aid purchased from a vendor not in the Funds’ directory will not be covered. However, if you already have hearing aids from a non-cooperating vendor and need repairs and the warranty is still in effect, that provider should perform any repairs. If the warranty has expired, the Funds will direct you to a cooperating vendor for the repairs.
Yes, the Funds covers routine eye exams, eyeglasses, and contact lenses once every 24 months with payment limitations. The beneficiary will be responsible for a significant portion of the charges for routine vision care. Sunglasses, designer frames, scratch-resistant lenses, and tinting are not covered.
Yes, if you need to schedule a medical appointment but do not have transportation, you may be eligible for non-emergency transportation benefits. Call 1-800-292-2288 and press option 4 to seek approval.
Yes, with a doctor’s order, skilled nursing care, physical therapy, and speech therapy may be provided by licensed personnel from a certified home health agency. For Medicare covered beneficiaries, Medicare is the primary payer and Medicare Part A must approve these services. Home health visits to assist with activities of daily living (bathing, feeding, and house cleaning, etc.) are not covered.
Subject to prior approval, coverage is provided for medically necessary skilled nursing care in a skilled nursing care facility. For Medicare covered beneficiaries, Medicare Part A covers the first 100 days of skilled care. The Funds can cover services in excess of 100 days if the Funds pre-certifies the services as skilled care. To pre-certify, the facility should call our Precertification Department at 1-800-292-2288. Nursing home stays for custodial care (personal care, feeding, toileting, etc.) are not covered.
Coverage is provided for immunizations, screenings for high blood pressure, diabetes, and other conditions, and for medically necessary tests to detect cancer, blindness, and deafness.
**Note – the 1993 Benefit Plan and the Prefunded Benefit Plan do not cover preventive care office visits for non-Medicare beneficiaries between the ages of 6 and 55.**
Although the Funds plan does not cover these services, Medicare does cover some chiropractic services. If you are eligible for Medicare and have elected the Funds as your Medicare Part B payer, the Funds will pay any chiropractic services that are covered by Medicare Part B. The beneficiary will be responsible for any copayments or coinsurance due after the Medicare Part B payment is made.
