How to use your benefits
The following is designed to help you better understand your health plan coverage. For additional information, refer to your member materials available in the Providence Health Plan secure member portal, myProvidence.
Select the topic you would like more information about:
New Providence members
New to Providence?
We make it easy to maximize your membership in minutes. Follow these easy steps to make the most of your health plan:
- Keep your member ID card close – you'll need your ID card to receive services, so keep it with you at all times.
- Register for your myProvidence account – Get access 24/7 to your secure health management member portal.
- Choose your primary provider – We make it easy to find a primary doctor or medical home you’ll love.
- Explore your care options – Understand when and where to receive different types of care.
- Get to know your plan benefits – Learn about your drug coverage, the claims process, and costs for services.
- Take advantage of your member perks – Your plan comes with a set of great perks to help you achieve your True Health.
Care management program and referrals
The Providence Care Management team will help you better understand your health so you can take an active role in improving it. Whether you need help understanding a new diagnosis or assistance navigating options for a diagnosis that has been affecting one’s life for a long time, Providence Care Management is here to help.
Care management services are voluntary, open to all Providence Health Plan members, and available at no cost. Members may self-refer into the program or be referred by providers, caregivers, hospital discharge planners or as a result from a recent hospital stay or diagnosis. See a list of conditions supported by Providence Care Management and learn more about the resources available to you based on your specific condition. You may also call Providence Care Management at 800-662-1121 (TTY: 711) Monday through Friday, 8 a.m. to 5 p.m. (Pacific Time), or email firstname.lastname@example.org to learn more and/or seek assistance.
Additional health management programs and services
Quality Management Mailer Program
PHP strives to improve member health outcomes by ensuring they receive recommended screenings. Our member mailing program aims to increase completion of these important screenings through both education mailings and gap mailings. Members who are eligible for screening according to clinical guidelines are sent mailers encouraging collaboration with their health care provider to ensure that appropriate testing is completed. Eligibility varies by mailing; members may meet criteria for more than one mailing.
Member mailings address a broad number of recommended clinical care, including:
- Adolescent wellness
- Childhood wellness
- Flu shot
- Blood pressure management
- 18-month immunization
- Respiratory health
- Women’s health
- Breast cancer screening
- Cervical cancer screening
- Colorectal FOBT
- Colorectal cancer screening
Health coaching program
If you are age 18 or older, you’re eligible for health coaching sessions provided either online or by phone at no cost to you. Your coach can help remove barriers that might keep you from achieving your goals, support your efforts, motivate you when you need a nudge, and be a resource on your journey to a healthier, happier you. You can use these sessions to meet a variety of goals. Learn more by completing a health coaching interest form or by calling 503-574-6000 or 888-819-8999 (TTY: 711).
Opioid Safety Program
Providence Health Plan is committed to keeping you safe and healthy. Even when taken as directed, there are risks associated with taking opioids (pain medication). If you have taken opioids for a prolonged period of time, you may receive a letter detailing information you may want to discuss with your provider. If you have any questions or need further assistance, please contact Providence Health Plan Pharmacy Services Department at 877-216-3644, 8 a.m. to 6 p.m. (Pacific Time), Monday through Friday.
Availability of external appeals
At Providence Health Plan, we take member satisfaction seriously. If you have an issue with or concern about your health plan coverage, contact us by phone or in person at the number and address listed on the back of your member ID card. We’re here to help.
Member rights and responsibilities
As a member of Providence Health Plan, you should know what to expect from us, as well as what we ask from you. Nobody knows more about your health than you and your doctor. We take responsibility for providing the very best health care services and benefits possible; your responsibility is to know how to use them well. Please take time to read and understand your benefits. We want you to have a positive experience with Providence Health Plan and we're ready to help in any way.
Privacy practices and protected health information, use and disclosure
At Providence Health Plan, we respect the privacy and confidentiality of your protected health information (PHI). We are required by law to maintain the privacy of your PHI, including in electronic format. PHI is information that identifies you as an individual, such as your name and Social Security Number, as well as financial, health, and other information about you that is nonpublic, and that we obtain so we can provide you with insurance coverage. Providence Health Plan maintains policies that protect the confidentiality of personal information, including Social Security numbers, obtained from its members during the course of regular business functions. We must provide you with this notice and abide by the terms of this notice. This notice explains how we may use and disclose information about you in administering your benefits and it also informs you about your rights as our valued member. Finally, this notice provides you with information about exercising these rights.
Read our full Notice of Privacy Practice
Benefits and services included in, and excluded from, coverage
Member materials, which include your member handbook and benefit summary or summaries, provide information about the benefits and services covered under your health plan; they also identify services that are limited and/or specifically excluded. Your member materials are available online in the Providence Health Plan secure member portal myProvidence, upon creation of a free account. If you prefer a printed copy of your member materials, please contact Providence Health Plan customer service.
Non-covered healthcare services
Services determined to be investigational, not medically necessary, or cosmetic in nature are not covered by your plan. Your health plan may review services on a case-by-case basis to determine medical necessity. Learn more and see list of services currently considered non-covered (PDF).
How Providence Health Plan evaluates new technology for inclusion as a covered benefit
New technology policy; new application of existing technology coverage determination
New technologies and new applications of existing technologies are evaluated and approved for coverage when they provide a demonstrable benefit for a particular illness or disease; are scientifically proven to be safe and efficacious; and there is no equally effective or less costly alternative.
Emerging and innovative technologies are monitored by Providence Health Plan through review of trend reports from technology assessment bodies, government publications, medical journals and information provided by providers and professional societies.
A systematic process for evaluating a new technology or new application of an existing technology is proactively initiated when sufficient scientific information is available.
Plan-developed standards guide the evaluation process to assure appropriate coverage determinations. New technology must minimally meet the following guidelines to be approved for coverage:
- Technology must improve health outcomes. The beneficial effects must outweigh any harmful effects on health outcomes. It must improve the length or quality of life or ability to function.
- Technology must be as beneficial as any established alternative. It should improve the net health outcome as much, or more than, established alternatives.
- Application of technology must be appropriate, in keeping with good medical standards and useful outside of investigational settings.
- Technology must meet government approval to market by appropriate regulatory agency as applicable.
- Criteria must be supported with information provided by well-conducted investigations published in peer-reviewed journals. The scientific evidence must document conclusions that are based on established medical facts.
- Opinions and evaluations of professional organizations, panels or technology assessment bodies are evaluated based on the scientific quality of the supporting evidence.
Technology evaluation process
A core committee of Providence Health Plan medical directors and high-level physician specialists, practitioners and/or pharmacists evaluate and recommend coverage for new technologies. Their decisions are based on information provided by professional assessment and policy development organizations, as well as other medical experts.
Prescription drug information
Providence Health Plan prescription drug plans provide benefit payment for medications listed on the formulary* and which are:
- Medically necessary for the treatment of a covered illness or injury
- Prescribed by a qualified practitioner for use on an outpatient basis
- Filled by an in-network pharmacy
*A formulary is a list of FDA-approved prescription preferred brand-name and generic drugs. Designed to offer drug treatment choices for covered medical conditions, it can help you and your qualified practitioner choose effective medications that are less costly and that minimize your out-of-pocket expense.
Refer to the pharmacy resources page for more prescription drug information and to view formularies.
Copays and other charges for which members are responsible
The amount you owe for services rendered is listed in your member materials available in myProvidence. Generally speaking, those amounts may be in the form of:
A percentage of the cost of a covered service. The provider will bill you for the amount due, if any.
Copay (also referred to as a copayment):
The fixed dollar amount you pay for a covered service at the time care is provided.
The amount you pay out-of-pocket before benefits kick in. Deductibles are usually per person and/or per family, per calendar year.
Services not covered by your health plan.
Usual, customary and reasonable (UCR):
Should you receive services from an out-of-network* provider, you may be liable for the difference between the health plan payment and the provider’s actual charge.
* Personal Option, Oregon Individual plans and Washington Individual plans do not offer out-of-network benefits.
Providence may require prior authorization for certain services. Learn more about prior authorization.
Transition of care
Once a member turns 18, it's time to transition out of pediatric care. The provider directory can help you find in-network providers, facilities and pharmacies. The directory is located at ProvidenceHealthPlan.com/findaprovider.
Some benefits, such as rehabilitation services, may be subject to an annual limit. Should you reach the annual limit and need further services, Providence Health Plan can assist you in finding resources. Call customer service at 800-878-4445 (TTY: 711) for assistance.
How to obtain language assistance
For language assistance, please contact Providence Health Plan customer service at 800-878-4445 (TTY: 711). NOTE: TTY, or text telephone relay, services enable those with hearing and/or speech impairments to communicate with others by telephone. There is no cost to use this is service.
How to submit a claim for covered services
Most providers will submit claims on your behalf to Providence Health Plan; however if you need to submit a claim, forms are available at ProvidenceHealthPlan.com/forms. Use the appropriate form (e.g., medical, mental health, alternative care, vision, etc.). Instructions for how to submit the claim are on the form.
How to obtain information about practitioners who participate in Providence's provider networks
In-network providers are listed in the provider directory. The directory includes provider contact information, in addition to other practitioner-provided information such as credentials, education, board certification(s), number of years in practice, languages spoken, and a short biography. Because provider networks vary by plan, search using your member ID number.
How to obtain primary care services
The provider directory includes in-network provider contact information in addition to other practitioner-provided information such as credentials, education, board certification(s), number of years in practice, languages spoken, and a short biography. Because provider networks vary by plan, search using your member ID number.
The following provides a general overview of how to access non-emergent care under different plan types. Please consult your member materials, available in myProvidence, for plan-specific information about how to access primary care services specific to your plan.
Choice or Connect plans:
Under the Providence Choice and Providence Connect plans, a member must select a medical home. (A medical home is a specially designated primary care clinic in which a care team delivers patient-centered care focused on improving the health of the patient.) The medical home coordinates the care a patient receives from multiple providers and caregivers and provides referrals as necessary.
Personal Option plan, and Oregon and Washington Individual plans:
These plans require that services be rendered by an in-network provider.
All other plans:
Referrals are not required; however, your primary care provider may refer you or you may refer yourself to an in-network provider. If your plan provides out-of-network benefits, you may self-refer to an out-of-network provider; however, be aware any plan coverage may be lower for out-of-network care and you may be responsible for the difference between the health plan payment and the provider’s actual charge.
How to obtain specialty care, behavioral health and hospital services
The following provides a general overview of how to access specialty care, behavioral healthcare, and hospital services under general plan types. For information specific to your plan coverage, please refer to your member materials available in myProvidence. To access your member materials, log in at myProvidence, select “My Health Plan” in the top navigation, then select “Benefit Documents” from the drop down menu.
Choice or Connect plans:
Most specialty, hospitalization, and behavioral health services require a referral, which is a written order from the primary care provider to see a specialist or get certain medical services. No referral is needed for outpatient office visits for mental health or chemical dependency. Many preventive services do not require a referral. If your plan includes coverage for vision and dental services, those services may be accessed without a referral. Some services require prior authorization. Your medical home will provide referrals and arrange for any necessary prior authorizations.
All other plans:
Your primary care provider may refer you or you may refer yourself to an in-network provider. To locate an in-network provider, please refer to the provider directory. Some services, including inpatient hospital services, require prior authorization. In-network providers arrange for any necessary prior authorizations. If your plan covers out-of-network services, you may self-refer to an out-of-network provider; however, this may result in greater out-of-pocket costs.
Referrals for Choice and Connect plans
All services received outside of your medical home will require a referral from your medical home provider with the exception of emergency and urgent care. Referrals are requested through your medical home provider. These services must be medically necessary and the referral must be to an in-network provider. Some services may require prior authorization in addition to a referral.
Services that require a referral may change. Contact customer service at 503-574-7500 or 1-800-878-4445 (TTY: 711) for assistance, or speak with your medical home provider if you have questions.
How to obtain care when outside of the service area
Providence Health Plan offers a national network of providers. To locate an in-network provider, refer to the provider directory. Covered services rendered by out-of-network qualified providers nationwide are eligible for benefits at the out-of-network benefit level. [NOTE: Personal Option plans, Oregon Individual plans and Washington Individual plans do not offer out-of-network benefits.]
Emergency care for covered services is available worldwide for all plans.
How to obtain emergency care
Emergency care services are provided both within and outside of the service area. If an emergency situation occurs, you should take immediate action and seek prompt medical care. Call 911 or the emergency number listed in the local telephone directory, or go to the nearest emergency room.
How to obtain care after normal office hours
There are several ways to obtain care after office hours:
- Your primary care provider’s office will generally have a physician on call to respond to questions and/or provide guidance outside of normal business hours.
- ProvRN, 24/7 nurse advice line offered free to plan members offers access to a registered nurse who can assess your symptoms to help you determine next steps for care.
- Conditions that need attention right away but are not life-threatening (e.g., minor cuts or burns; ear, nose and throat infections; sprains or strains; headaches or dizziness) can be treated at an immediate (non-emergency) care facility.
- In the event of an emergency, call 911 or go directly to the nearest emergency facility. Emergency care is most appropriate for accidents or sudden, unexpected injuries or illnesses that may result in serious medical complications, permanent disability or death if treatment is not sought immediately (e.g., severe chest pain, loss of consciousness, bleeding that doesn't stop, severe abdominal pain, sudden paralysis or slurred speech, etc.).
Benefit restrictions that apply to services obtained outside of Providence Health Plan's service area
Benefits for otherwise covered services obtained outside the Providence Health Plan service area vary by plan type; please refer to your member materials in myProvidence for information specific to your plan. To access your member materials, log in at myProvidence, select “My Health Plan” in the top navigation, then select “Benefit Documents” from the drop down menu.
How to voice a complaint
In the event you have a complaint, please contact Providence Health Plan customer service. Representatives are available to provide information and assistance. For more information, please refer to the Problem Resolution section of your member handbook.
How to appeal a decision that adversely affects coverage, benefits or a member's relationship with the organization
Mental health and Substance Use Disorder treatment services for members on Washington medical plans
Classification of Mental Health and SUD treatment and access standard
Mental health and Substance Use Disorder treatment services are characterized as specialty services when provided by behavioral and/or mental health professionals. This means that you must be able to access mental health or substance use disorder treatment services within 15 business days according to Washington law.
How an enrollee can find in-network mental health and substance use disorder treatment and services in their service area
You can find in-network providers by visiting our Provider Directory, available online at http://phppd.providence.org/ or calling Customer Service at 1-800-878-4445 to get information about a mental or behavioral health provider’s participation with Providence Health Plan and your benefits.
Steps an enrollee may take if they cannot access services in the required timelines
If you are having trouble making an appointment please call 1-800-878-4445 to speak with an intake specialist who will help you identify your needs and, if needed, facilitate an individualized appointment search.
How enrollees may file a complaint with WA OIC
If you would like to file a complaint with the Washington state Office of the Insurance Commissioner you may contact them at www.insurance.wa.gov or call 1-800-562-6900.
- Disciplinary action for failure to meet network access standards (no action against Providence Health Plan) (link coming soon)
- Washington Office of the Insurance Commissioner annual access standards and consumer complaints report (link coming soon)
Resources for persons experiencing a mental health crisis
- Suicide Prevention Hotline
The Suicide Prevention Hotline is 800-273-8255.
- Emergency Resources
If this is an emergency or you think you may harm yourself, call 911.
Resources for Substance Use Disorders
Additional information regarding behavioral health services and resources are available to Providence Health Plan members. To access these resources, sign in to https://myprovidence.com. Information and resources are found on both the behavioral health resource page and under Health Topics.