• Covered professional providers

We provide benefits for the services of covered professional providers, as required by Section 2706(a) of the Public Health Service Act. Covered professional providers within the United States, Puerto Rico, and the U.S. Virgin Islands are healthcare providers who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill, or are paid for their healthcare services in the normal course of business. Covered services must be provided in the state in which the provider is licensed or certified. If the state has no applicable licensing or certification requirement, the provider must meet the requirements of the Local Plan. Your Local Plan is responsible for determining the provider’s licensing status and scope of practice. As reflected in Section 5, the Plan does limit coverage for some services, in accordance with accepted standards of clinical practice regardless of the geographic area.

Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex, pregnancy or genetic information.

If you have questions about covered providers, would like the names of PPO (Preferred) providers, or need a Care Coordinator for complex conditions, please contact the Local Plan where services will be performed.