Get answers to the most common questions about PPO plans.
Q. What should I do if I have an emergency when I’m out of the area?
A. A medical emergency is defined as a sudden illness or injury so severe that the average person would believe that immediate medical attention is needed to avoid serious health damage or bodily harm.
If you have an emergency outside the CDPHP service area, go to the nearest hospital emergency room. CDPHP will cover the hospital emergency room bill in full — minus your copayment or deductible and coinsurance. If the situation is urgent but not an emergency, such as a sore throat, sprain, or infection, contact the CDPHP Resource Coordination Department at 1-800-274-2332 for advice in obtaining the care you need.
Q. How do I access my out-of-network benefits?
A. With your PPO plan you have coverage for care from non-participating providers but you should understand that your costs will be higher than seeking care within the network. Please refer to the benefit materials provided to you at the time of enrollment for specifics on your out-of-pocket costs. These vary according to the plan purchased by your employer group.
Q. Do I have to choose a PCP to direct my care?
If you have PPO coverage you do not need to select a PCP. However, we still recommend that you establish yourself with a doctor who will deliver your routine services and coordinate your care with specialists. Please use Find-A-Doc to view the range of doctors available within the CDPHP network.
Q. How do I submit a claim?
A. If you’ve received a covered service and the provider of medical services requested that you pay the charge at the time of service, send a completely itemized bill to our office so that you receive the maximum available benefits. That bill should include:
- Provider’s name, address, telephone number, and tax ID number
- Date of service
- Name of each procedure/procedure code, including the name of any drugs
- Charge for each procedure
- Receipt for any payment made
- Member’s name and ID number
Please send claim to: Capital District Physicians’ Health Plan, Inc., P.O. Box 66602, Albany, NY 12206-6602.
Note: this same process applies to claims for care you received out of the country.
Q. Can I order my prescription drugs by mail?
A. Yes. The CDPHP Mail Order Prescription service is available to members who have a prescription drug rider and who take maintenance medication.