There is no “in network” or “out of network.” In this plan, there are only coordinated and uncoordinated tiers when understanding where and how your insurance will pay.
Primary Care:
- If you signed up for Direct Primary Care, you will be a primary care patient at NeighborsMed. This practice located at ….. is membership only. If you did not sign up initially, and would like to do so, please reach out to the Direct Health Plan team.
- If you did not sign up for NeighborsMed, you will have a membership at ModRn Health. They are not technically a Direct Primary Care, but instead, a virtual first provider for you to discuss health, referrals, prescriptions and more. They can send referrals for care and copy the Direct Health Plan on your behalf for coordination.
- If you would like to see a different primary care provider, please let the Direct Health Plan team know, and we will work to coordinate on your behalf. While you will still have ModRn support, visits to another primary care can be coordinated or uncoordinated.
Outside of Primary Care:
- If your visits is referred by ModRn Health or NeighborsMed and coordination is completed by the Direct Health Plan, you will be ready of a no to low cost appointment with no confusion.
- If you would like to see a specialist, please let the Direct Health Plan team know, and we will work to coordinate on your behalf. If you do not let the Direct Health Plan team know about an appointment with a provider, there may be additional costs and confusion.
Coordination of all visits with the Direct Health Plan team is the best way to make sure you will not have to come out of pocket more than you should.
Yes. Preventative care as defined by the Federal Government is covered, but this does not mean that this care will be $0 to the member.
https://www.healthcare.gov/coverage/preventive-care-benefits/
Plan financial guidelines, coordinated tiers, and uncoordinated tiers apply.
Be careful! – Some Low Country hospitals try to make a fortune on this class of care. We see price gouging $2,000 mammograms and $15,000 colonoscopies regularly. Don’t get stuck with a bill. Your best bet is coordination!
Reach out to the Direct Health Plan team immediately.
More and more, billing for a single visit is broken up between parties in an attempt to maximize reimbursement or hide charges. We will work on this on your behalf.
In complex cases or surgeries, there could be as many as 5 or 6 different parties (often related) sending bills. We may have already paid these on your behalf or they may not be owed.
This may also be a balance bill and there could be additional member or plan responsibility.
Please call, text, or email the Direct Health Plan and we can assist
OR
Log in to: portal.directhealthplan.com
Use the navigation bar to click on Claims, Buckets, Overview, and more.
Reach out to the Direct Health Plan if there are questions or if you have trouble logging in or navigating.
If your visit was coordinated and you received a text prompt after swipe:
If your visit was coordinated (plan Visa or you paid cash) and you did not receive a prompt:
If your visit was uncoordinated and you paid cash:
If your visit was uncoordinated and a claim was filed:
Log in to: portal@directhealthplan.com
Use the navigation bar to click on Claims, Buckets, Overview, and more.
Reach out to the Direct Health Plan if there are questions!
No. There are not coordinated and uncoordinated tiers for pharmacy.
Use your insurance card at the pharmacy to get great pricing, access copays (Copay Plan), or to have your expense apply to deductible (HDHP Plan).
Go to www.serveyourx.com to find the best pricing near you and more.
If you can find better pricing, by all means, pay cash. This will not apply to your deductible.
*Tip – Walgreens and CVS are often the most expensive. Grocery stores, independent pharmacies, Walmart, and Costco are often less expensive for you.
Privacy laws governing a dependent’s control over personal health information (PHI) vary significantly by state. In some jurisdictions, certain healthcare privacy rights may vest at younger ages, including as early as age 13 for specific services or circumstances.
Because the Plan operates across multiple states and serves employees and dependents residing throughout the United States, it is not practical to administer state-specific authorization requirements on an individual basis. Accordingly, the Plan requests that any dependent who wishes to allow a parent, guardian, spouse, or other authorized representative access to their protected health information complete a PHI Authorization that is valid for Plan operations nationwide. This approach helps ensure compliance with varying state privacy requirements while allowing the Plan to effectively support members and their families.
The ER is for emergencies only and there is no time for you or the Direct Health Plan to coordinate.
Claims will be submitted and processed according to plan guidelines.
To find out what you may have elected, please reach out to the Direct Health Plan or log in to the portal and scroll to the bottom of your profile. This will either say ModRn Health or NeighborsMed.
Should you wish to change your election, please reach out to the Direct Health Plan.
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What Coordination Means
Coordination means that you, ModRN Health, or NeighborsMed have contacted us before an upcoming appointment and provided the information needed to review the request.
Coordination is not instantaneous. We need at least 48 hours for basic services and more time for complex cases or surgeries.
Coordination helps confirm that:
- The provider’s accepted payment amount falls within plan guidelines.
- The requested service medically fits plan guidelines.
- Larger or more complex cases receive independent medical prior authorization when required.
In most cases, coordination can be completed with limited member involvement. More complex cases may require your support, medical records, provider notes, or physician orders.
How Coordination Works by Plan Type
Copay Plan
When care is coordinated, you have a $0 medical deductible. You will present as self-pay rather than having the provider file a claim. When payment is required, we will send a virtual debit card.HDHP Plan Before Your Deductible Is Met
When care is coordinated before you meet your deductible, coordination helps secure lower pricing for you out of pocket. Amounts you pay apply 100% toward your deductible. You will present as self-pay and should be prepared to pay at the time of service. In this situation, we do not send payment.HDHP Plan After Your Deductible Is Met
When care is coordinated after your deductible has been met, you have a $0 medical deductible. You will present as self-pay and should be prepared to pay at the time of service. When payment is required, we will send a virtual debit card. -
Important Reminder
Reaching your deductible or maximum out-of-pocket limit does not guarantee that a service will be paid by the plan. All services remain subject to plan terms, conditions, exclusions, limitations, medical necessity requirements, and prior authorization requirements where applicable.
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What Uncoordinated Care Means
Uncoordinated care means that you, ModRN Health, or NeighborsMed did not contact us before an appointment or service with the information necessary to coordinate care – OR – you opted out of the coordinate pathway and decided to go to a non-coordinated provider, facility, visit.
Uncoordinated events include situations where:
- We were not given at least 48 hours for basic services and more time for complex cases or surgeries to coordinate care.
- You presented your insurance card and had a claim filed rather than presenting as self-pay.
- The provider’s pricing or payment expectations fall outside of plan guidelines.
- Required medical prior authorization was not obtained – no coverage in this case.
- The requested service does not meet medical plan guidelines – no coverage in this case.
How Uncoordinated Care Is Processed
When care is uncoordinated, the plan will process claims according to plan guidelines and limitations.
- The plan will pay only up to the amount allowed under plan guidelines.
- Providers may seek additional payment from you if they are unwilling to accept the plan’s allowed amount.
- Amounts applied toward your deductible and out-of-pocket maximum are based on plan-allowed member responsibility, which may differ from the amount you actually paid.
- Services that do not meet medical plan guidelines are considered non-covered and are not eligible for reimbursement.
- Services requiring prior authorization that was not obtained are considered non-covered and are not eligible for reimbursement.
In some situations, partial coordination may be possible. When this occurs, the plan may pay, reimburse, or apply toward your deductible only the portion of the expense that meets plan guidelines.
How Uncoordinated Care Works by Plan Type
Copay Plan
When care is uncoordinated, you do not receive the coordinated care benefit of a $0 medical deductible. Standard copays, deductible expenses, and out-of-pocket accumulators apply according to plan provisions.HDHP Plan Before Your Deductible Is Met
Uncoordinated care may result in higher out-of-pocket costs and less favorable pricing. The amount applied toward your deductible may be less than the amount you actually paid.HDHP Plan After Your Deductible Is Met
Uncoordinated care may result in higher out-of-pocket costs and less favorable pricing. The amount applied toward your deductible or out-of-pocket maximum may be less than the amount you actually paid.Important Reminder
Reaching your deductible or maximum out-of-pocket limit does not guarantee that a service will be paid by the plan. All services remain subject to plan terms, conditions, exclusions, limitations, medical necessity requirements, and prior authorization requirements where applicable.
The Direct Health Plan team. We have nearly instantaneous access to all of your pharmacy transactions and can usually help you right away.
Should there be questions about prior authorizations or rejections, we will work to get answers ASAP.
Copay Plan
Copays (prescriptions and medical) DO NOT apply to your deductible but do apply to your maximum out of pocket.
Uncoordinated allowable charges apply to your deductible and maximum out of pocket.
HDHP Plan
All covered (not exceeding plan guidelines) medical and rx expenses apply to your deductible and maximum out of pocket.
Uncoordinated allowable charges apply to your deductible and maximum out of pocket.