YOUR SPECIALTY CARE Coverage that’s focused on you
Do you need prior authorization? My PCP (or other in-network provider) recommended I visit a specialist. In-network provider With a Dean Health HMO or Focus Plan, in-network provider — you don’t need to do anything. Although the service may require a prior authorization, it’s up to your in-network provider to get prior authorization for you. Out-of-network provider With a Dean Health HMO or Focus Plan, out-of-network provider prior authorization is needed to see an out-of-network provider. Discuss this with your plan physician and they will submit an authorization to the health plan if the services are not available with plan providers. We’ll then review the request and provide a written decision to both you and the referring provider within 15 calendar days from receipt. Make sure you wait until you receive this approval before receiving the recommended services to avoid any unnecessary fees. PPO or POS plan Because each POS and PPO plan is different, we recommend you check if a prior authorization is required for any services outside of a normal office visit. For a plan-specific list of these services, refer to the “Prior Authorization” section of your Member Certificate (sometimes called “Member Policy”) available at MemberBenefits. Deancare.com . You may also call 1 (800) 279-1301 ( TTY : 711) for help. † If Member Services is unable to address your authorization concerns, you’ll be connected to the Care Management Department. If you have an urgent need outside of business hours, leave a message with Member Services and your call will be returned within one business day.
In addition to primary care providers, our network includes a variety of medical specialties. Your primary care provider can help you find the specialist who is right for you. Specialty care 101 If you’re ever unsure, you can talk to your primary care provider about when a specialist is needed. • Examples of specialty care include physical therapy, podiatry, chiropractic services and dermatology • There are many specialists affiliated with Dean Health Plan, including but not limited to SSM Health • You should be seen by a specialist within the Dean Health Plan network of providers Visit Deancare.com/Doctors for a comprehensive list of our specialty providers, behavioral health services and hospitals. Prior authorization Certain medical services or specialty care services might require you to get prior authorization.* • Anytime you seek services with an out-of-network provider, you need prior authorization unless your benefit plan includes an out-of-network option • Prior authorization allows our medical management team to review the medical necessity of the recommended service or visit and make sure you’re getting appropriate care. * A prior authorization can only be obtained for services that are covered under your plan benefits. For example, if bariatric surgery isn’t covered in your policy, prior authorization will not change the policy to cover it. If the services are covered under your plan, they remain subject to a decision regarding medical necessity and any applicable cost sharing (e.g., copays, coinsurance or deductibles).
Visit DeanCare.com or call 1 (800) 279-1301 ( TTY : 711) | 15
14 | 2024 Group Member Guide
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