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:


  • Care management program and referrals

    Providence’s 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 can self-refer into the program or be referred from providers, caregivers, hospital discharge planners or as a result from a recent hospital stay or diagnosis. Learn more about the resources available to you based on your specific condition through Providence Care Management. You may also call Providence Care Management at 800-662-1121 (TTY: 711) or email caremanagement@providence.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, and members may meet criteria for more than one mailing.

    Member mailings address a broad number of recommended clinical care, including:

    • Adolescent wellness
    • Childhood wellness
    • Diabetes
    • Flu shot
    • Blood pressure management
    • 18-month immunization
    • Respiratory health
    • Women’s health
    • Opioid
    • HbA1c
    • Statin
    • Breast cancer screening
    • Cervical cancer screening
    • Colorectal FOBT
    • Colorectal cancer screening

    For more information about the Quality Management Mailer Program, please contact us at PHPQualityManagement@providence.org.



    Health coaching program

    If you are age 18 or more, 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 received 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. We encourage anyone who has a problem or concern about health plan coverage to contact us by phone or in person at has a problem or concern about health plan coverage to contact us by phone or in person at the phone number and address listed on his or her member ID card. We’re here to help.


    Learn more
  • 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.


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  • Privacy practices and protected health information (PHI), 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 protected health information, (commonly called PHI or your personal information) including in electronic format. When we use the term “personal information” we mean 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 in the course of its 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:


    Coinsurance:

    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.


    Deductible:

    The amount you pay out-of-pocket before benefits kick in. Deductibles are usually per person and/or per family, per calendar year.


    Non-covered services:

    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.

     

  • 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, and 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 which contain submission information, are available in the Member section of this site. use the appropriate* form, all of which are available at ProvidenceHealthPlan.com/forms. Instructions for how to submit the claim is indicated on the form.

    * e.g., medical, mental health, alternative care, vision, etc.

  • 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:

    Members may choose any qualified licensed provider; however, we recommended that members choose an in-network primary care provider because:


    • In-network benefits are generally better than out-of-network benefits, resulting in lower out-of-pocket costs for members.
    • In-network providers arrange any necessary prior authorizations, agree to file claims on the member’s behalf, and accept usual, customary and reasonable (UCR) charges (What's this?) as payment in full.
    • While having a primary care provider is not required, studies show there are benefits to having an ongoing relationship with a primary care provider. Learn more about our primary care providers here.
  • 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.


    Choice or Connect plans:

    A referral is required for all services except outpatient provider visits for mental health and chemical dependency and those services covered by a rider (e.g., dental, prescription drug, vision, and/or alternative care coverage). Some services, including inpatient hospital 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 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.

  • 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.


    Learn more
  • 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. Urgent care or 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.

  • 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
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