Point of Service
(POS) Overview
Frequently Asked
Questions
A Point of Service
(POS) plan allows you to receive services from network or
non-network providers. Claims payment is determined at the
point of where you receive services (POS) or where you receive
care. You are responsible for set copayment amounts if services
are received within the plan’s network of providers.
If services are obtained from non-network providers, you are
responsible for a deductible and coinsurance amounts.
Network Benefits
In order to obtain maximum benefits from your POS plan, use
network providers. Mercy Health Plans in the Southwest region
requires the use of Primary Care Physicians (PCPs). Features
include:
- No deductibles.
- Set copayments.
Contact your medical plan
for specific benefit information.
Non-network Benefits
A POS plan includes non-network benefits at reduced levels. If you receive medical services from non-network providers, you are responsible for:
- Meeting a deductible.
- Ppaying coinsurance amounts.
- Obtaining pre-authorization for surgeries, medical procedures
and hospital admissions.
- Charges above the usual, customary and reasonable (UCR)
amount.
The out-of-pocket maximum places a cap on the amount you
pay for eligible expenses in each calendar year. Once your
share of these expenses reaches the out-of-pocket maximum
set by your plan, the plan pays 100% of all remaining covered
expenses for the calendar year.
Claims
If you use a non-network provider, it is your responsibility
to file the claim with your medical plan. To file a claim,
contact your POS plan to
find:
- How, when, and where to obtain claim forms, if required, and
- The requirements for providing notice of claim and proof of loss. If it was not reasonably possible to give notice within the specified time, claims shall not be invalidated or reduced.
For non-network services, claims
must be filed within 12 months of the date of service.
 |
Home
