GULF SOUTH HEALTH PLANS WAS THE FIRST MANAGED CARE ORGANIZATION IN LOUISIANA TO EARN FULL ACCREDITATION FROM THE NCQA.
FREQUENTLY ASKED QUESTIONS
What is the advantage of using the Network and going through my Primary Care Physician?
There are several advantages: your financial liability is limited to the applicable copayments and you may not have to file claims (unless you are covered by Medicare or another group policy).
In addition, by having your Primary Care Physician provide or arrange all of your health care, one physician has a "complete picture" of your health history at all times.
What is a "referral"?
A "referral" is authorization by your Primary Care Physician to see a Network Specialist. Your Primary Care Physician will notify Gulf South of the referral by telephone. Gulf South will document the referral and telephone approval to the specialist's office. You must obtain the referral before seeing a Network specialist for Network benefits to apply. If you directly access a Network specialist and then try to obtain a referral, Non-Network benefits will apply. Once your PCP makes the referral, you may schedule an appointment with the specialist.
When do I need a referral?
You must obtain referral authorization from your Primary Care Physician to see a Network specialist. A referral is necessary when seeing any Network specialist, with the following exceptions:
Must I schedule an office visit and see my Primary Care Physician every time I need to see a specialist?
You must have referral authorization from your Primary Care Physician to ensure Network benefits for visits to a Network specialist, even if you are already in treatment with that specialist. If you see a Network specialist without referral authorization from your Primary Care Physician, Non-Network benefits will apply. However, your Primary Care Physician may, at his/her discretion, authorize several visits to a specialist with one referral. This will depend on the relationship you have established with your Primary Care Physician and on your treatment history. If you are currently in treatment with a Network specialist, it is important that you inform your Primary Care Physician of this treatment.
Can I see any doctor I want and still be covered?
Yes. However, if you "directly access" a Network Provider (other than the Primary Care Physician whose name appears on your ID card), or if you use the services of a Network Provider, Non-Network benefits apply. You are encouraged to see your Primary Care Physician and to have him/her make necessary Specialist referrals.
Can I use any hospital and still be covered?
Yes. However, if you choose to go to a Non-Network hospital for a non-emergency admission, Non-Network benefits are payable, even if your admitting physician is your Primary Care Physician or authorized referral Specialist. In addition, you are responsible for obtaining preadmission certification by notifying Gulf South prior to your non-emergency admission to a Non-Network hospital.
What can I do in an emergency to ensure I receive Network benefits?
Please referr to our Guidelines for Emergency Room Access page.
What is the certification penalty?
The certification penalty is applied when a) you do not notify Gulf South before being admitted to a Non-Network hospital for non-emergency services; b) when you do not notify Gulf South before being admitted to a Network hospital by a Non-Network physician for non-emergency services; c) when you do not notify Gulf South before being admitted to any hospital for non-emergency services if the admission has not been authorized by your Primary Care Physician; and d) when you do not notify your Primary Care Physician or Gulf South within the proper time limit after being admitted to a hospital for emergency inpatient services. It is your responsibility to obtain certification or preadmission certification in all of these situations.
The certification penalty means that benefits are reduced to 50% of the first $10,000 of eligible charges. The 50% of eligible charges not covered will be your responsibility, and that amount does not apply to your deductible, nor does it apply to your out-of-pocket maximum. Therefore, it is to your advantage to obtain preadmission certification when required.
If I require hospitalization and wish to use a Network hospital, but I would prefer to be under the care of a Non-Network physician, do Network benefits apply to my hospital charges?
Network benefits would apply to the hospital charges only if a) your Primary Care Physician has recommended that you be hospitalized and you utilize a Non-Network physician as surgeon or attending physician; or b) your Primary Care Physician has referred you to a Network specialist who has recommended hospitalization, but you utilize a non-network physician as surgeon or attending physician. In either case, your Primary Care Physician must have approved the hospitalization before services are rendered by a Non-Network physician in order for hospital charges to be considered at Network benefits. In addition, if you use a Non-Network physician, Non-Network benefits will apply to his or her charges, and you must ensure that preadmission certification is obtained for your hospital stay prior to admission.
Is preventive health care covered under this plan?
Preventive care and well-child care are covered only when provided or authorized by your Primary Care Physician. There are no Non-Network benefits for preventive health care.
Is ambulance service covered?
Medically necessary ambulance service is covered with Network benefits in an emergency if your Primary Care Physician is notified within the proper time limit or if it is authorized by your Primary Care Physician and Gulf South's Medical Director.
Can I use any pharmacy?
Yes. However, Non-Network benefits will apply if you have prescriptions filled at a Non-Network pharmacy, even if the prescription is written by a Network physician.
Which medications are on Gulf South's Preferred Drug List?
Click the following link for Gulf South Health Plans' Preferred Drug List. You will pay a "preferred brand" or Tier 2 copayment for drugs on this list. This list is effective January 1, 2000 and is subject to change. Remember: Your benefit design determines what is covered for you and what your copayment will be. Specific dollar limitations may apply. Please refer to your benefit masterials for specific coverage information.
Are prescriptions written by a Non-Network physician covered? (Applies only if you have prescription drug coverage.)
Yes, although Non-Network benefits will apply, even if the prescription is filled at a Network pharmacy.
Are birth control pills covered?
Birth control pills are covered only if prescribed by a network physician and filled at a Network pharmacy.
Can I see my GYN without authorization by my Primary Care Physician?
Yes, you may directly access a Network GYN for gynecological related services and receive Network benefits. Non-routine gynecological care rendered by a Non-Network GYN are payable at Non-Network benefits. Routine GYN services (e.g., preventive or "well"care) are not covered when provided by a Non-Network physician.
Are well-baby care and other preventive services covered?
Only when provided or arranged by your baby's Primary Care Physician. There are no Non-Network preventive health care benefits.
Do I have to file claims?
For Non-Network services, the provider is not obligated to perform this service for you. For Network services, in most cases, the provider accepts assignment and files a claim directly with Gulf South. However, please check with your physician's office for their specific claims filing procedure. If you or any of your covered dependents are covered by Medicare or another group policy, you may be required to file claims on your behalf.
If Gulf South is secondary to Medicare or other group insurance for you or any of your dependents, we will require an explanation of benefits for each claim from the primary carrier before we can complete processing of your claims.
Will each of my dependents have his/her own ID number?
Yes. Your dependents will be identified by your Social Security Number and a suffix. In addition, each dependent will be issued his/her own ID card which will include the name and telephone number of his/her Primary Care Physician.
What if a forget to tell my Primary Care Physician or authorized Network Specialist I am a member, I am billed, and I pay? Can I be reimbursed?
It is your responsibility to identify yourself as a Gulf South member and to show your ID card prior to receiving services. Any reimbursement would be limited to Non-Network benefits.
My spouse is covered under group insurance through his employer. Does he still have to identify himself as a Gulf South member when receiving services?
Yes. In order for Network benefits to be considered, even when Gulf South is the secondary insurer, Network providers must be utilized and all Network procedures must be followed. Otherwise, only Non-Network secondary benefits will be considered.
If my children are covered under my Point-of-Service Plan and my spouse's group plan, how do we determine which plan is primary for our family members?
Since your group. primary for your children.
What if my Primary Care Physician refers me to a Non-Network provider?
Network benefits would apply only if your Primary Care Physician and Gulf South's Medical Director determine that care is not available within the Network. Otherwise, Non-Network benefits would apply.
You will receive a letter from the Member Advocate letting you know how your appeal will be handled. At each level of the appeal process, you will be informed of your right to appeal further should you choose to do so. Gulf South also offers an independent, external appeal review process at no cost to members. The independent process is used for only specific types of appeals. If you have any questions about the appeal process, please contact Member Services for additional information.
If you have additional questions, or if we may clarify a benefit issue, please call our Member Services Representatives. Our highly trained staff will be happy to assist you.
IN LOUISIANA: 1-800-237-3583, extension 1980