Medical Provider Networks
U.S. Medical Provider Network - First Health International
In the U.S., when you call
a Physician’s office or present your ID card, it is important for you to say: “My health care plan utilizes the First Health International Network. Are you a First Health International participating provider?”
For assistance in locating a First Health provider, please visit their website or call 1-800-226-5116. First Health will assist you in locating the provider type or specialist in your area.
ASPE Health Benefits Plan contains a Medical Provider Network inside the U.S. A Medical Provider Network is a group of Physicians and medical facilities that have entered into an agreement with the Medical Network to accept discounted fees for medical services. The Medical Provider Network is a Preferred Provider Network (PPO). Claims for services provided by a Preferred Provider are mailed directly to Seven Corners at the address on the back of your Identification Card.
If you receive your medical services from one of the Physicians or facilities in the Medical Provider Network,
your benefits will be paid at the negotiated provider contracted rate, if they are Covered Services. Also, if you use a provider in the Medical Provider Network, the provider cannot bill you for any Covered Services except the Copay amount.
Usual, Customary & Reasonable Charges (UCR)
If you do not receive care from a provider in the Medical Provider Network, benefits will be paid at standard Usual, Customary and Reasonable Charges (UCR) for the area in which care was delivered if they are a covered benefit. If the provider bills more than UCR, you will be responsible for any charges over and above the UCR, as non-preferred providers are not under negotiated contracted rates.
35 Mile Exemption
If your home address is over 35 miles from the nearest in-network medical provider, you are exempt from the provider network guideline. You are free to see any provider of your choice. You will need to call Seven Corners to coordinate this exemption.
Out of Network Charges
If you pay for your medical services out-of-pocket or are billed at the time of service you will need to submit a claim for payment or reimbursement.
If you want to discuss your provider choice with Seven Corners, you can call Customer Service toll free in the U.S. at 1-800-461-0430.
Do not wait to find a provider for emergency care - go straight to the nearest ER. Emergency care is defined by Seven Corners as a need for hospitalization, trauma (ie: broken bones, accidents), acute and spontaneous non-controllable pain, blurry vision, intense headache, chest pain, shortness of breath, unmanageable high fever, open wounds, or any life-threatening situation.
If you have a life-threatening emergency, please call your local emergency service or go to the nearest hospital. If you are unsure where the nearest hospital is located, the Seven Corners staff can assist.
International Medical Provider Network
To locate a physician or hospital in the Non-U.S. Medical Provider Network, call Seven Corners at 1-800-461-0430 or 317-818-2867; or visit www.wellabroad.com.
Exchange Participants on grants outside the U.S. may seek treatment from any provider of their choice. Seven Corners has a Medical Provider Network outside of the U.S. Seven Corners offers wellabroad.com, which allows Exchange Participants to locate providers overseas who are associated with their Non-U.S. Medical Provider Network.
Seven Corners has built Usual, Customary, and Reasonable rate tables for specific regions outside of the United States, to ensure your Covered Expenses do not exceed local rates for Covered Services. Seven Corners will attempt to facilitate financial arrangements with Non-U.S. medical providers on the Exchange Participant’s behalf, but Exchange Participants should be prepared to pay out-of-pocket and seek claim reimbursement. When you have health care coverage other than ASPE (except Medicare or Medicaid), your other coverage is the primary payer and must pay claims first up to the limit of its policy.
In case of an Emergency, during which the Exchange Participant is outside the United States, Seven Corners should be contacted immediately. We ask that you provide as many details as possible to our staff during this call. Our office can be reached 24/7 by calling 1-800-461-0430 or 317-818-2867.
Emergency care overseas is defined by Seven Corners as a need for hospitalization, trauma (ie: broken bones, accidents), acute and spontaneous non-controllable pain, blurry vision, intense headache, chest pain, shortness of breath, unmanageable high fever, open wounds, or any life-threatening situation.
Seven Corners is available to support you with an emergency number and guide you to a Direct Pay or Referral Provider, but clearly we want you to seek immediate care at the nearest facility.
In emergency situations where care is needed immediately, you are not required to call Seven Corners. If you have a life-threatening emergency, please call your local emergency service or go to the nearest hospital.