How to Access Covered Care
Choose your doctor and change anytime.
Getting in-depth information on how your plan works and getting connected with a provider who suits your individual needs is the first priority. Choose from a wide range of great providers or stay with your current provider. And, remember—you can change at any time. Your plan provides you with that flexibility. However, the benefits provided under the In-Network Provider Tier and Out-of-Network Provider Tier, are not the same. Some services are covered only at the In-Network Provider Tier.
Here’s an overview of getting care with Choice Products. In the Added Choice 2 Tier (POS) plan, there are two Tiers to choose from: In-Network Provider Tier and Out-of-Network Provider Tier.
In-Network Provider Tier
Kaiser Permanente Providers
Many ways to access care through Kaiser Permanente.
- Your care in the Kaiser Permanente network starts with your own personal doctor—your primary care physician—who will coordinate your care. You choose your own doctor and you can change your doctor at any time.
- You can also see most specialists without a referral.
- You can manage your care at kp.org. Visit any time from anywhere to make an appointment, refill most prescriptions, see most lab results, and much more.
- You could also have a video or telephone visit with a doctor at no extra cost.
With Kaiser Permanente Providers, you’ll usually pay the lowest out-of-pocket costs with no or a lower deductible.
Out-of-Network Provider Tier
Any other licensed provider or physician
Call any licensed provider’s office directly.
- Your Out-of-Network Provider Tier benefits cover care you receive from any licensed provider (outside the In-Network Provider Tier).
- You can call the provider’s office directly to make an appointment.
- You don’t need a referral for Out-of-Network Providers or specialists. However, you will need prior authorization for some services and procedures. You must call 1-800-221-2412 (TTY 711) for prior authorization.
- Your doctor may require you to pay the full cost of the visit. And you will need to submit claim forms and itemized bills for reimbursement.
- You’ll have to pay coinsurance and meet a deductible. You’ll also be responsible for any difference between what your provider charges for service and the payment Kaiser Permanente Insurance Company provides.
Helpful Tips
- When making an appointment. Make sure the provider understands that your plan allows you to see any licensed provider.
- When checking in for your visit. Bring your ID card with you. If your provider has any questions, have them call the customer service phone number on the back of your ID card.
- After your visit. When you receive services from an Out-of-Network Provider, you will need to submit a claim and you will be responsible for paying the difference.
You’ll generally pay the most out-of-pocket costs when you receive services from an Out-of-Network Provider or facility.
It’s important to keep in mind:
- Your cost-shares will vary in each provider Tier.
- The amount you pay for a particular service will depend on the provider Tier you choose and—in some cases—where you choose to receive care.
To find out more:
- See your Choice Products POS Member Resource Guide for details about accessing covered care using the different Tiers.
- Refer to your Evidence of Coverage (EOC).
- Contact the human resources/benefits officer where you work, if your employer provides your coverage. Call Customer Service at 1-855-364-3185 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m., Eastern time, or refer to your ID card.
Kaiser Foundation Health Plan (KFHP) of Georgia, Inc., underwrites the In-Network Provider Tier and Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., underwrites the Out-of-Network Provider Tier. Some services require prior authorization. For more information, see your Evidence of Coverage (EOC).