Behavioral Health Services are managed by PHP. Call PHP Customer Service at 517.364.8500.

PHP creates benefit plans in which your cost for a medical service, for instance an office visit, is equal to a similar service for behavioral health or substance abuse. This ensures the benefits are equal, and you don’t pay any more for behavioral health services than you would for the same type of medical service.

The deductible, copayment and coinsurance amounts are your responsibility to pay to your healthcare providers.

• A deductible is the amount you pay for healthcare services before your PHP insurance starts to pay.
• A copayment is a fixed amount you must pay each time you receive certain covered health services.
• Coinsurance is a percentage of the allowed cost for a covered service.

Preventive services are performed to screen for possible health issues when you do not have symptoms, and have not had a previous abnormal test result. An office visit, test, or procedure could all be considered preventive.

In order to be considered as preventive, services must be billed with specific preventive billing codes. Your provider’s biller will use industry standard coding guidelines to complete a claim for the service you received. PHP cannot change the coding to fit one type of benefit or another.

Diagnostic services are performed when you have symptoms, an abnormal test result, or a known health problem. An office visit, test, or procedure could all be considered diagnostic. The services may be performed to determine the cause of symptoms or to verify if a disease has returned or gotten worse.

If you have family or personal history, abnormal test results, or known health problems associated with the procedure, the service will most likely be considered diagnostic. There is also a possibility that you have no history or symptoms, but during the procedure an issue is identified.

For questions regarding how your benefits applied to a service, contact our Customer Service call center at the phone number on the back of your ID card.

Contact your provider's office for more details if your question pertains to why a procedure is being billed as a diagnostic service.

An Observation Stay is an outpatient hospital service in which an individual receives medical treatment to help the doctor decide whether he/she should be admitted to the hospital as an inpatient, or whether he/she should be discharged. Observation Stays may occur when patients go to the emergency room and have symptoms that require hospital physicians to monitor them. Observation Stays can last as little as a few hours but may also last several days.

Your emergency room benefit will apply if you are kept for observation following services in the emergency room.

A hospital-based outpatient clinic is a physician practice which is considered part of the hospital instead of a private physician office. These clinics may look like a regular doctors' office, but they are either in a partnership with a hospital or are a hospital-owned physician practice.

Hospital-based clinics are still considered part of the hospital even though they may be located miles away from the main hospital, across the street from the hospital, or inside of the hospital. Often, they are dependent upon the hospital for administrative services such as billing, staffing, and payroll, or equipment such as MRI, CT and laboratory.

To determine if your doctor is part of a hospital-based outpatient clinic or private office, ask your doctor how they will be billing services to your health insurance plan.

An Explanation of Benefits (EOB) is an explanation of how we processed a claim for you or a family member. An EOB is not a bill. EOBs are always addressed to the patient to protect patient confidentiality. An EOB shows the patient’s name, member number, claim number, name of provider and type of service, dates of service, billed charges, amounts not covered, deductible and copayments, and total patient cost. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.

Copies of your Explanation of Benefits (EOB) can be found by creating or logging into your MyPHP account. Access to your MyPHP account is found at www.PHPMichigan.com under the “Portal Login” tab.

You can create a MyPHP account if you don’t currently have one.

• Go to www.PHPMichigan.com 
• Click on Portal Login
• Click on MyPHP Member Portal
• Choose Create An Account and fill in the requested information.

Please call the PHP Customer Service department at 517.364.8500 if you have trouble creating an account or accessing your EOB.

Out of network services are from doctors, hospitals, and other health care professionals that do not have a contract with PHP. Out of network providers may set higher cost for services than providers who are in network with PHP. Depending on the provider, the service could cost more or not paid for at all.

• Under the new legislation, if you or your representative are given and sign paperwork provided by an out-of-network provider that includes a disclosure form and a cost estimate at least 14 days in advance of your planned service (or within 14 days if your planned service is sooner), you agree to be balance billed by the out-of-network provider. You bear liability in this instance.
• In a non-emergency situation at an in network facility, you may receive services from an out of network provider. If the out of network provider fails to give you the required disclosure before or within 14 days of your planned service, you cannot be balance billed. Only your applicable coinsurance, copayment or deductible should apply.
• Emergency ground ambulance services are not covered under surprise billing. You should refer to your insurance policy and contract language for coverage details.
• Check your EOB for applicable copays.

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is surprise billing?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Some of the most common specialties that result in surprise bills include anesthesiologists, radiologists, pathologists, and emergency room physicians.

You’re protected from balance billing for:

Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Note: surprise billing law does not apply to ground ambulance services. You should refer to your insurance policy and contract language for coverage details.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia,pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can no longer send you surprise bills without written disclosure and consent for planned services.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

A medical emergency is defined as a serious medical condition or symptom resulting from an accident, injury, sickness, or mental illness that arises suddenly and has severe symptoms, including severe pain. It is further defined as being a situation in which a reasonable person would believe that failure to get immediate care may result in:

• Placing the patient’s health in serious danger
• Serious harm to body functions
• Serious harm to any body organ or part
• Serious disfigurement
• In case of a pregnant woman, serious jeopardy to the unborn child

Urgently needed health services are defined as health services that are required in order to prevent serious deterioration of a person’s health, and that are required as a result of an unforeseen sickness or injury. See the chart below for a few examples.

PHP covers you at the network-benefit level for emergency and urgent conditions, even if you are traveling away from home. If you have an emergency, go to the nearest emergency room. If your situation is urgent, go to the nearest urgent care facility. We will also cover a non-network physician’s office visit for urgent care while traveling out of the area. Contact PHP as soon as possible after your treatment, so that follow-up care can be provided, and your medical record can be updated.

For Emergency Situations
If you have a serious injury or sudden illness with severe symptoms, call your primary care physician (PCP) and follow the instructions you are given. If you are unable to contact your doctor and have someone to transport you safely, go directly to the nearest hospital emergency room. If you don’t have enough time to contact your doctor and you need immediate assistance, call 911 and stay on the line until instructed to hang up. Emergency staff can get to you faster than you can get to the hospital. Contact PHP as soon as possible after your treatment, so that follow-up services can be provided.

Urgent Situations
Urgent care should be used in a situation that is not life-threatening but that requires care sooner than you can typically schedule an office visit. If you need urgent care during normal office hours, after doctor’s office hours or on the weekends, call your PCP for direction. Your PCP may direct you to obtain urgent care services at a network urgent care facility or may arrange to see you personally on an urgent basis.

If you need urgent care after your doctor’s office hours or on the weekend, call your primary care physician’s office. Their after-hours recording may instruct you on how to obtain urgent care services. Go to the nearest urgent care facility or emergency room if you are unable to contact your doctor, and you have an injury or illness with symptoms that require immediate attention.

A claim is a request to an insurance company for payment of healthcare services. Usually, providers file claims with us on your behalf. If you received services from an out-of-network provider, and if that provider does not submit a claim to us, you can file the claim directly to PHP up to 12 months from the date the services were rendered. Please contact PHP Customer Service at 517.364.8500 to determine the specific time limit for submitting your claim.

Before you obtain certain medical services, PHP must review and approve them. This is called prior authorization or pre-service review. For example, any kind of inpatient hospital care (except maternity care) requires prior authorization. If you need a service that we must first approve, your doctor will call us for the authorization. If you do not receive prior authorization, you may have to pay up to the full amount of the charges. The number to call for prior authorization is included on the ID card you receive after you enroll. Please refer to the specific coverage information you receive after you enroll.

PHP typically decides on requests for prior authorization for medical services within 24-72 hours for urgent requests, depending upon the type of request, or within 7 days for non-urgent requests.

Medical Claims:

Please fill out the Medical Reimbursement Form, which can also be found on the Member Reference Desk Submit the completed form along with an itemized receipt showing the charges for the services you received, and the information outlined below.

If you are unable to print the form, submit an itemized receipt and the following information. Please include a brief description indicating that you are seeking reimbursement.

• Provider name, address, phone number and Federal Tax ID number
• Date of service
• Place of service (e.g., urgent care, emergency room, etc.)
• Diagnosis
• Procedure and/or procedure code
• Patient’s name and PHP ID number

Medical claims should be sent to:
Physicians Health Plan
P.O. Box 30377
Lansing MI 48909-7877

Fax: 517.364.8411

Pharmacy Claims:

Please fill out the Pharmacy Direct Reimbursement Form and submit an itemized receipt showing the charges for the services you received:

• Member name
• Pharmacy name
• Drug name
• National Drug Code (NDC)
• Quantity dispensed
• Day supply
• Provider name
• Date of service
• Amount paid

Pharmacy claims should be sent to:
CVS Caremark
P.O. Box 52136
Phoenix, Arizona 85072-2136

Fax: 517.364.8411

Check the status of a medical or pharmacy claim by visiting MyPHP, our online account management resource, or call PHP Customer Service at 517.364.8500.

If you are an individual member whose premium payment is past due, you are provided a grace period. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. For more information on grace periods, see the Premium Payments section below.

You may make changes to your mailing address on MyPHP or by calling PHP Customer Service at 517.364.8500. You should also notify your employer of any change in address.

To receive a new card, please request one online through MyPHP or contact PHP Customer Service at 517.364.8500. If you are concerned about the unauthorized use of your ID card or the information contained on it, please contact PHP Customer Service at 517.364.8500.

You should always notify your employer and PHP whenever someone is no longer eligible for coverage. Ex-spouses become ineligible on the date of divorce, and dependents become ineligible if they do not meet certain dependent requirements as specified by your policy. Please call PHP Customer Service at 517.364.8500 whenever you have questions.

If you have coverage through your employer, contact your employer. Your employer will notify PHP of your changes.

If you have coverage through a PHP Individual plan, fill out the change form and return to PHP.

If you have coverage through a PHP Individual Marketplace plan, contact the Marketplace.

PHP complies with the Consolidated Appropriations Act, 2021 – Broker Compensation Disclosure, and has outlined below the Individual Commission and Bonus Program offered to PHP’s broker/agent partners.

All individual members are billed the same premium regardless if they use a broker/agent to enroll, or if they enroll independently through PHP or Healthcare.gov.

• Broker/Agents earn a 4% commission on all new and renewed individual premiums.
• Broker/Agents are eligible for a one-time bonus for each newly enrolled subscriber.

PHP will continue to provide new or updated information as it becomes available.

COB exists when you are covered by more than one health plan. The plans typically process Medical claims together, reducing your out-of-pocket expenses. COB rules tell each health plan who pays first (also referred to as the primary health plan). The primary plan provides full benefits as if there were no other plans involved. The other plan then becomes secondary. Further information about coordination of benefits can be found in your benefit booklet.

Outpatient Prescription Drug Product Benefits are not coordinated with those of any other health coverage plan. If you have primary healthcare coverage and this benefit plan is your secondary coverage, you must use your primary outpatient prescription drug coverage.

The policy you have through your employer, or the policy that lists you as the policy holder, will most likely be billed first, however there are exceptions that are based upon the type of policy. If you have any questions as to which policy should be billed first, call PHP Customer Service at 517.364.8500.

Please call PHP Customer Service at 517.364.8500 as soon as possible if you are involved in an accident and had medical services as a result of the accident. You may also receive a letter from a subrogation vendor on behalf of PHP asking for more information about certain injuries.

You may receive a notice from us asking you to tell us about any other medical coverage that you or your dependents have. Please follow the directions on the notice so that we have the most up-to-date information and can pay your medical claims correctly. Information regarding other health coverage can be provided at any time by logging into your MyPHP member portal or by calling our PHP Customer Service Department at 517.364.8500. If you do not provide us with your other insurance information, we may deny or delay paying your claims.

Outpatient pharmacy benefits are categorized within six tiers – Tier 1A, Tier 1B, Tier 2, Tier 3, Tier 4 and Tier 5. The higher the tier, the higher your copay. Refer to your benefit plan for more information about your copays.

Prescription drug lists , also known as formularies, are chosen by your employer for your benefit plan. Pharmacy benefits are provided by CVS/Caremark . You can verify the drug coverage you have by contacting PHP Customer Service at 517.364.8500 or 800.832.9186, or by visiting CVS/Caremark. If you are a first-time user of CVS/Caremark, you will need to register with your PHP subscriber number.

These lists are subject to change.

Call PHP Customer Service at 517.364.8500. If it is urgent, we will contact an on-call nurse to assist you.

If your Physician prescribes a prescription drug in a classification or tier that is not available to you, we conduct, at you or your Physician’s request, a review to determine if the drug is medically appropriate in your specific circumstances. We notify you and your provider of our coverage decision within 9 calendar days of receipt for a standard request. If your situation is urgent, we make our decision and notify your Physician within 72 hours of receiving an expedited request.

You may initiate a request for exception by asking PHP for a prior approval via email or phone. You may submit your request via email -- using the secure Contact Us Form on our website -- or phone by calling the PHP Customer Service Department at 517.364.8567 or 866.539.3342. You must submit:

• Your name
• PHP ID number
• The name of the prescribing Physician or Physicians coordinating your treatment
• The drug in question

We will contact your Physician to get your medical information. In most cases, your Physician will submit the request on your behalf. The Medication Prior Authorization Form should be used for any exception requests. The completed form and supporting information from either you or your Physician can be faxed to the PHP Pharmacy Department at 517.364.8413.

A standard request for a non-formulary and excluded medication will receive notification of a coverage decision, sent to both you and your provider, within 72 hours of receipt. If your situation is urgent, we make our decision and notify you and your physician within 24 hours of receiving an expedited request.

If your request is denied for a non-formulary and/or excluded medication, alternative drug choices may be suggested. You, a personal representative, or prescribing provider also can ask for an independent review of your request via phone, mail or fax. The independent review must be completed within the same time-period as the original request (72 hours for a standard request or 24 hours for an expedited request.)

To accommodate the needs of new members, we may, upon clinical review, cover a non-formulary drug for a limited period of time.

You may initiate a request for exception by asking PHP for a prior approval via email or phone. You may submit your request via email -- using the secure Contact Us Form on our website -- phone by calling the PHP Customer Service Department at 517.364.8567 or 866.539.3342 or mail at 1400 East Michigan Avenue, Lansing, Michigan 48910. You must submit your name, PHP ID number, the name of the prescribing Physician or Physicians coordinating your treatment and the drug in question. We will contact your Physician to get your medical information. In most cases, your Physician will submit the request on your behalf. The Medication Prior Authorization Form should be used for any exception requests. The completed form and supporting information from either you or your Physician can be faxed to the PHP Pharmacy Department at 517.364.8413.

Discuss the use of generic drugs with your physician. Generic drugs must have the identical active ingredients as the brand name drug. The differences can be color, shape, fillers and flavor. If you or your provider have questions, please call PHP Customer Service at 517.364.8500.

Premium payments can be made online with a credit card, debit card or bank withdrawal by going to PHPMichigan.com/choosephpmi.com and selecting the “Make A Payment” option. Payments can be made using our 24-hour automated payment system at 855.850.2265, or you can pay by check to the address listed below.

Physicians Health Plan
P.O. Box 74008122
Chicago, IL 60674-8122

When using the “Make A Payment” option for online payments, please be sure you are using the Account Number, which is on your invoice and in your online account. This is the number that starts with the number “1” and has 10 digits. If you do not have this number, please use the option to find your account using your social security number.. If you have questions or are still unable to find your account, contact PHP Customer Service at 517.364.8567.

You are required to pay your monthly premium by the scheduled due date, which is indicated on your premium invoice. The premium due date is the last day of the preceding month. Your coverage could be cancelled if you fail to make your payment by the due date.

For policies not receiving a Premium Tax Credit:
If you do not pay your monthly premium on time you will receive a 30-day grace period, ending on the last day of the month your premium was due. A grace period is a time period when your coverage will not terminate even though you did not pay your monthly premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If you do not pay your delinquent premium by the end of the 30-day grace period, your coverage will be terminated retroactively to the last paid month. If you pay your full outstanding premium before the end of the grace period, PHP will pay all properly submitted claims for covered services you received during the grace period.

For policies receiving a Premium Tax Credit:
If you do not pay your monthly premium on time you will receive a 3-month grace period. PHP will pay all properly submitted claims for covered services during the first month of the grace period. During the second and third months of that grace period, any claims you incur will be pended. If you pay your full outstanding premium before the end of the 3-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the 3-month grace period, your coverage will terminate, and PHP will not pay for any pended claims submitted for you during the second and third months of the grace period. Your coverage will be retroactively terminated back to the end of the first month of your grace period. Your provider may balance bill you for services incurred during the second and third months of your grace period.

A retroactive termination of coverage is the reversal of coverage for months in which your premiums were not paid. A retroactive claim denial is the reversal of a claim we have already paid but is now after your coverage has ended. If we retroactively deny a claim we have already paid for you, you will be responsible for payment. You can avoid retroactive denials by paying your premiums on time, and in full.

If you believe you have paid too much for your premium and should receive a refund, please call PHP Customer Service at 517.364.8567.

Refunds in the exact amount of your credit card, debit card or automatic bank withdrawal payment, made no more than 6 months ago, can be refunded directly to the method of payment. This refund should be reflected in the payment account within 7-10 business days. If your refund was made by check or money order, or was made more than 6 months ago, the refund will be issued by check. This refund check will be mailed by PHP within 4-6 weeks. Please allow mailing time for the payment to reach you.

Visit the Finding a Doctor page for information about doctors and hospitals in-network for the plan type you have. PHP Customer Service staff is also available to help you with answers to your important physician-related questions:

• Will the doctor accept new patients?
• What are the office hours and where is the doctor located?
• Is the physician board certified?
• Is the hospital accredited?
• What hospitals can the doctor work with?
• How many years has the physician been in practice?
• Where did the doctor go to school?
• Does the physician speak your language?

If you are a new member or if your doctor leaves the PHP network, you must pick a network doctor. You may be able to see your current doctor for up to 90 days, depending on the care you are currently receiving. If you are pregnant, special case-by-case consideration may be given. To learn more, contact the Medical Resource Management Team at 517.364.8560.

A referral is a recommendation from one doctor to another, commonly from your primary care provider to a specialist. PHP does not require a referral, but the specialist you want to see may require the information.

A prior authorization is PHP approval for a healthcare service. Not all healthcare services require PHP prior authorization. You or your doctor should submit the request for prior authorization before you receive the service using the authorization request form. Non-urgent requests are reviewed within 7 days. Urgent requests are reviewed in 72 hours. The request may be approved or denied. We will send you and your physician a letter with the decision.

PHP does not require referrals to in-network specialists. However, some specialists may still require a referral from your primary care physician (PCP). If your specialist still wants a referral from your PCP, call your PCP and tell him or her that your specialist is asking for a referral.