There is no “in network” or “out of network.” In this plan, there are only coordinated and uncoordinated tiers when understanding where and how your insurance will pay.

Primary Care:

1. During plan election, you will be given the option of multiple Direct Primary Care Offices in the Upstate of SC.  Please take your team, reach out to the offices, and determine what will be best for you!
2. If you would like to change your Direct Primary Care office during the plan year, please let the Direct Health Plan team know, and we will do our best to move your membership the following month.  

Outside of Primary Care:

1. If your visit is referred by your Direct Primary Care and coordination is completed by the Direct Health Plan, your visit is considered coordinated.
2. If your specialist orders additional services, those orders are considered an extension of the care event started by your primary care and can be considered “coordinated.”  The Direct Health Plan team will just need to know the details to begin the coordination process.
   1. For example, your Direct Primary Care doctor refers you out to a cardiologist and this doctor orders a cardiac stress test. The initial visit to the cardiologist can be coordinated by the DPC referral and the cardiac stress test orders will need to be sent to the Direct Health Plan…and can also be coordinated!    

Coordination of all visits with the Direct Health Plan team is the best way to make sure you will not have to come out of pocket more than you should.

Yes. Preventative care as defined by the Federal Government is covered, but this does not mean that this care will be $0 to the member.

https://www.healthcare.gov/coverage/preventive-care-benefits/

Plan financial guidelines, coordinated tiers, and uncoordinated tiers apply.

Be careful! – Some Upstate hospitals try to make a fortune on this class of care. We see price gouging $2,000 mammograms and $15,000 colonoscopies regularly. Don’t get stuck with a bill. Your best bet is coordination!

Reach out to the Direct Health Plan team immediately.

Often, billing for a single visit is broken up between parties in an attempt to maximize reimbursement or hide charges. We will work on this on your behalf.

In complex cases or surgeries, there could be as many as 5 or 6 different parties (often related) sending bills. We may have already paid these on your behalf or they may not be owed.

This may also be a balance bill and there could be additional member or plan responsibility.

Please call, text, or email the Direct Health Plan and we can assist

OR

Log in to: portal.directhealthplan.com

Use the navigation bar to click on Claims, Buckets, Overview, and more.

Reach out to the Direct Health Plan if there are questions or if you have trouble logging in or navigating.

Why would I upload receipts?  

If cash was paid either by the plan’s VISA or by you, a receipt will be required for proper adjudication or possibly reimbursement.  Always ask for as detailed of a receipt as possible!

Log in to: portal@directhealthplan.com

Use the navigation bar to click on Claims, Buckets, Overview, and more.

Reach out to the Direct Health Plan if there are questions!

No.  There are no coordinated and uncoordinated tiers for pharmacy.

Use your insurance card at the pharmacy to get great pricing, access copays (Copay Plan), or to have your expense apply to deductible (HDHP Plan).

Go to www.serveyourx.com to find the best pricing near you and more.

If you can find better pricing, by all means, pay cash. This will not apply to your deductible.

*Tip – Walgreens and CVS are often the most expensive. Grocery stores, independent pharmacies, Walmart, and Costco are often less expensive for you.

Privacy laws governing a dependent’s control over personal health information (PHI) vary significantly by state. In some jurisdictions, certain healthcare privacy rights may vest at younger ages, including as early as age 13 for specific services or circumstances.

Because the Plan operates across multiple states and serves employees and dependents residing throughout the United States, it is not practical to administer state-specific authorization requirements on an individual basis. Accordingly, the Plan requests that any dependent who wishes to allow a parent, guardian, spouse, or other authorized representative access to their protected health information complete a PHI Authorization that is valid for Plan operations nationwide. This approach helps ensure compliance with varying state privacy requirements while allowing the Plan to effectively support members and their families.

The ER is for emergencies only and there is no time for you or the Direct Health Plan to coordinate.

Claims will be submitted and processed according to plan guidelines.

To find out what you may have elected, please reach out to the Direct Health Plan or log in to the portal and scroll to the bottom of your profile to find the name of the practice.

portal.directhealthplan.com

Should you wish to change your election, please reach out to the Direct Health Plan.

• What Coordination Means

  Coordination means that you, your Direct Primary Care doctor, or another providers office have contacted us before an upcoming appointment and provided the information needed to review the request.

  Coordination is not instantaneous. We need at least 48 hours for basic services and more time for complex cases or surgeries.

  Coordination helps confirm that:

  • The provider’s accepted payment amount falls within plan guidelines.
  • The requested service medically fits plan guidelines.
  • Larger or more complex cases receive independent medical prior authorization when required.

  In most cases, coordination can be completed with limited member involvement. More complex cases may require your support, medical records, provider notes, or physician orders.

  How Coordination Works by Plan Type

  Copay Plan
  When care is coordinated, you have a $0 medical deductible. You will present as self-pay rather than having the provider file a claim. When payment is required, we will send a virtual debit card.

  HDHP Plan Before Your Deductible Is Met
  When care is coordinated before you meet your deductible, coordination helps secure lower pricing for you out of pocket. Amounts you pay apply 100% toward your deductible. You will present as self-pay and should be prepared to pay at the time of service. In this situation, we do not send payment.

  HDHP Plan After Your Deductible Is Met
  When care is coordinated after your deductible has been met, you have a $0 medical deductible. You will present as self-pay and should be prepared to pay at the time of service. When payment is required, we will send a virtual debit card.

• Important Reminder

  Reaching your deductible or maximum out-of-pocket limit does not guarantee that a service will be paid by the plan. All services remain subject to plan terms, conditions, exclusions, limitations, medical necessity requirements, and prior authorization requirements where applicable.

• What Uncoordinated Care Means

  Uncoordinated care means that you, your Direct Primary Care, or another provider’s office did not contact us before an appointment or service with the information necessary to coordinate care – OR – you opted out of the coordinate pathway and decided to go to a non-coordinated provider, facility, visit.

  Uncoordinated events include situations where:

  • We were not given at least 48 hours for basic services and more time for complex cases or surgeries to coordinate care.
  • You presented your insurance card and had a claim filed rather than presenting as self-pay.
  • The provider’s pricing or payment expectations fall outside of plan guidelines.
  • Required medical prior authorization was not obtained – no coverage in this case.
  • The requested service does not meet medical plan guidelines – no coverage in this case.

  How Uncoordinated Care Is Processed

  When care is uncoordinated, the plan will process claims according to plan guidelines and limitations.

  • The plan will pay only up to the amount allowed under plan guidelines.
  • Providers may seek additional payment from you if they are unwilling to accept the plan’s allowed amount.
  • Amounts applied toward your deductible and out-of-pocket maximum are based on plan-allowed member responsibility, which may differ from the amount you actually paid.
  • Services that do not meet medical plan guidelines are considered non-covered and are not eligible for reimbursement.
  • Services requiring prior authorization that was not obtained are considered non-covered and are not eligible for reimbursement.

  In some situations, partial coordination may be possible. When this occurs, the plan may pay, reimburse, or apply toward your deductible only the portion of the expense that meets plan guidelines.

  How Uncoordinated Care Works by Plan Type

  Copay Plan
  When care is uncoordinated, you do not receive the coordinated care benefit of a $0 medical deductible. Standard copays, deductible expenses, and out-of-pocket accumulators apply according to plan provisions.

  HDHP Plan Before Your Deductible Is Met
  Uncoordinated care may result in higher out-of-pocket costs and less favorable pricing. The amount applied toward your deductible may be less than the amount you actually paid.

  HDHP Plan After Your Deductible Is Met
  Uncoordinated care may result in higher out-of-pocket costs and less favorable pricing. The amount applied toward your deductible or out-of-pocket maximum may be less than the amount you actually paid.

  Important Reminder

  Reaching your deductible or maximum out-of-pocket limit does not guarantee that a service will be paid by the plan. All services remain subject to plan terms, conditions, exclusions, limitations, medical necessity requirements, and prior authorization requirements where applicable.

The Direct Health Plan team.  We have nearly instantaneous access to all of your pharmacy transactions and can usually help you right away.

Should there be questions about prior authorizations or rejections, we will work to get answers ASAP.

Copay Plan

Copays (prescriptions and medical) DO NOT apply to your deductible but do apply to your maximum out of pocket.

Uncoordinated allowable charges apply to your deductible and maximum out of pocket.

HDHP Plan

All covered (not exceeding plan guidelines) medical and rx expenses apply to your deductible and maximum out of pocket.

Uncoordinated allowable charges apply to your deductible and maximum out of pocket.