Alliance Coal Direct and Non-Direct Providers
Each time you or a covered dependent needs medical care, you can choose any health care provider. The level of benefit coverage you receive depends on the provider’s status:
- Alliance Coal Direct providers are hospitals, doctors, and other health care providers that have direct contracts with the Alliance Coal Health Plan.
- Non-Direct providers are health care providers that are not Alliance Coal Direct providers.
Alliance Coal Direct Providers
Alliance Coal Direct providers are hospitals, doctors, and other health care providers that have direct contracts with the Alliance Coal Health Plan. These are individual contracts between the Plan and the provider. The Plan does not utilize networks or preferred provider organizations (PPOs).
The Plan’s online directory lists the providers that currently have an Alliance Coal Direct agreement. In addition, you can call Member Services toll-free at (855) 979-5192 for help with working to arrange a pre-negotiated agreement (such as a “single case agreement” or “bundled care package”) with a health care provider. If the Plan is able to arrange a pre-negotiated agreement for the care you need, the eligible services and supplies included in the agreement will be covered at the Alliance Coal Direct benefit level.
An Alliance Coal Direct provider typically accepts the Plan's Allowable Charge as payment in full. Please note that the Alliance Coal Direct benefit level applies only for services and supplies that the Plan considers to be eligible expenses and that are included in the provider’s contract with the Plan. Therefore, you are encouraged to ask Member Services during the preauthorization process whether a certain service or supply from a certain provider is eligible for the Alliance Coal Direct benefit level. For example, Cochlear (ear) implants currently are eligible for coverage only at Surgery Center of Oklahoma.
The Non-Direct benefit level applies if you choose a provider that does not have a contract or pre-negotiated agreement with the Plan for the services or supplies you receive. Non-Direct providers will bill you for any deductible/coinsurance/copay amounts that are your responsibility to pay.
For a Non-Direct provider, the Allowable Charge may be different than the provider’s charge. Under the Plan’s “Assignment of Benefits” provision, a health care provider who accepts an Assignment of Benefits is deemed to agree to accept the amount paid by the Plan (together with any coinsurance, deductible, and/or copayment paid by you) as payment in full for the services rendered or supplies provided. However, some Non-Direct providers might bill you for the difference between the provider's charge and the Allowable Charge. This is called a “balance bill." If you would like to discuss your options for resolving a balance bill with your provider, contact Member Services at (855) 979-5192.
Keep in mind that, even if an Alliance Coal Direct doctor or provider refers you to a Non-Direct provider, the Non-Direct benefit level applies to services or supplies from the Non-Direct provider. In addition, Direct doctors or providers may be supported by Non-Direct ancillary providers (see “Ancillary Services” below for information about the benefit level that applies in those situations). Before using any Non-Direct provider, you may want to call Member Services at (855) 979-5192 for assistance in identifying an Alliance Coal Direct provider.
You pay more when . . . you choose a provider that does not have an Alliance Coal Direct agreement for the service or supply you receive. Benefits are paid at the Non-Direct benefit level.
You pay less when . . . you choose an Alliance Coal Direct provider. Benefits are paid at the Alliance Coal Direct benefit level. For assistance in identifying Alliance Coal Direct providers, call Member Services at (855) 979-5192.
For designated procedures, the Plan has identified Centers of Expertise. When you use a Plan-approved Center of Expertise for these procedures, the Plan pays 100% of Allowable Charges, and you avoid a 40% benefit penalty.
Your Health Plan ID Card
Remember to always carry your Health Plan ID card with you.
You should always show your Health Plan ID card to your providers – before services are rendered – and ask them to confirm whether their services will be covered at the Alliance Coal Direct level. If your providers have questions about the Plan’s Allowable Charge and the Plan’s procedures, you can encourage them to call Provider Services at (855) 979-5194.
Note: You or your provider must properly file a claim within 12 months after expenses were incurred to receive reimbursement under the Plan.
If you are having a procedure performed by an Alliance Coal Direct surgeon/physician at an Alliance Coal Direct hospital/facility, ancillary services may be billed by doctors and other providers that are not Alliance Coal Direct. “Ancillary services” refers to certain health care services (such as anesthesiologists and radiologists) that support the work of the main surgeon/physician performing the procedure.
Generally, if you don’t have a choice regarding the ancillary service provider at an Alliance Coal Direct facility, the Alliance Coal Direct benefit level will apply; this applies only for providers with whom you can’t make an appointment (i.e., they do not keep office hours or see patients in a clinic-type setting). This means:
- For an unscheduled or emergency procedure that is performed at an Alliance Coal Direct facility, the Alliance Coal Direct benefit level will apply for all ancillary services related to that procedure (regardless of whether the ancillary service providers are Alliance Coal Direct).
- For a scheduled procedure that is performed at an Alliance Coal Direct facility or an Alliance Coal Direct physician's office, the Alliance Coal Direct benefit level will apply if:
- The ancillary services are performed by Alliance Coal Direct providers, or
- The ancillary services are performed by Non-Direct providers and the main surgeon/physician is employed by and bills through an Alliance Coal Direct provider.
- If you have a choice about who provides a laboratory or radiology/imaging service or procedure (even if your provider attempts to schedule the service or procedure for you), the service or procedure will only receive the Alliance Coal Direct benefit level if it is performed by an Alliance Coal Direct provider. For example, assume your doctor directs you to have a blood draw and suggests that you use a laboratory that is adjacent to the doctor’s office. However, you are free to use another laboratory. In that case, you will only receive benefits at the Alliance Coal Direct benefit level if the laboratory that provides the service is an Alliance Coal Direct provider.
To receive the Alliance Coal Direct benefit level for a scheduled procedure, verify that both the hospital/facility and the main surgeon/physician are Alliance Coal Direct providers. Contact Member Services at (855) 979-5192 for assistance.