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SMC|Enrollment Development|International Education Center|Preferred Provider Organization (PPO)

Preferred Provider Organization (PPO)

Medical Insurance 2013-2014

Preferred Provider Organization “PPO”

 

Please read the following information so you will know from whom or what group of providers health care may be obtained.

This Plan has incorporated access to a network of medical professionals, including Doctors and Hospitals, known as the Preferred Provider Organization (PPO). This PPO is available through the First Health Network. Network access provides benefits nationwide for Eligible Expenses incurred at 100% of the Allowable Charges when treated by network providers (PPO). Benefits are provided worldwide for Eligible Expenses incurred at 70% of Reasonable and Customary Expenses (R&C) when treated by non-network providers (non-PPO). However, if such treatment is received in a non-PPO facility due to an Emergency Medical Condition, benefits for Eligible Expenses are payable at the PPO level.

When a Covered Person has incurred $5,000 of out-of-pocket Eligible Expenses for all conditions during a policy year (not including Copays), the Company payment for Eligible Expenses incurred will increase to 100% of R&C for most Eligible Expenses, for the remainder of the policy year, up to the Maximum Benefit.

If a Covered Person is being treated by a Preferred Provider for an acute, serious chronic condition, pregnancy, newborn, or a terminal illness, and the Provider’s contract terminates with the PPO, the Covered Person may be eligible under certain conditions to continue treatment with the Provider at the PPO rate. Contact the claims administrator for details.

For a complete listing of the PPO Hospital and Doctor facilities, go to www.myfirsthealth.com or call 1-800-5116.

Please be aware that if you are treated at a PPO Hospital, it does not mean that all providers at that Hospital are PPO providers. In addition, if you are referred by a PPO provider to another provider or facility, it does not mean that that the provider or facility to which you are referred is also a PPO provider. For instance, when a network provider refers you to a lab for tests, be sure it is a network lab. This information can be found on the network website listed above.

The following Hospitals and Urgent Care Centers are First Health Network (FHN) facilities:

 

  • Santa Monica UCLA Medical Center and Orthopedic Hospital..........1-310-319-4000
    Emergency Center...........................................................1-310-319-4870
    1250 Sixteenth Street
    Santa Monica, CA 90404
  • Saint John’s Health Center.................................................1-310-829-5511
    Emergency Room................................ ............................1-310-829-8212
    2121 Santa Monica Blvd. (Main Entrance)
    2128 Arizona Avenue (Emergency Room Entrance)
    Santa Monica, CA 90404
  • Ronald Reagan UCLA Medical Center..... .................................1-310-825-9111
    757 Westwood Plaza
    Los Angeles, CA 90095
  • Access Medical Group................. .......................................1-310-306-6966
    Urgent Care
    4644 Lincoln Blvd Suite 111
    Marina Del Rey, CA 90292
  • ​West LA Urgent Care..........................................................1-310-390-9551
    11600 Venice Blvd.
    Los Angeles, CA 90066

 The use of the following non-PPO facilities also allows for 100% compensation of R&C charges:

  • Les Kelley Family Health Clinic...............................................1-310-319-4700
    1920 Colorado Ave.
    Santa Monica, CA 90404
  • Westside Family Health Center..............................................1-310-450-2191
    1711 Ocean Park Blvd.
    Santa Monica, CA 90405

 

Continued Stay Review

The Utilization Review Organization will contact the Covered Person’s Doctor periodically for a review of the medical information to determine the need for continued inpatient Hospital care. Additional days will be certified if they are determined to be necessary. If the Covered Person incurs additional inpatient charges that are not certified, these charges will not be covered.

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