What is a PPO? A preferred provider organization (PPO) is a network of medical care providers that have agreed to provide medical care services for negotiated fees. Members of a PPO are encouraged to utilize participating providers. As an incentive, the PPO plan pays a higher level of benefits for those members who use participating providers. Those members who use non-participating providers can expect to receive a lower level of benefits and higher out of pocket exposure.

Primary Care Physicians Primary care physicians (PCP) can be family practitioners, general practitioners, internal medicine practitioners or pediatricians. However, PPO members are not required to select a primary care physician. PPO members are also not required to obtain a referral in order to see a specialist. Advantages of Using Participating Providers Utilizing a participating provider keeps your out-of-pocket expense to a minimum. By using a participating provider, not only are your benefits paid at a higher level, but the providers have contracted with your insurance carrier at a negotiated rate, meaning that your coinsurance amounts will be based on their negotiated rate, not the usual and customary rates that non-participating providers charge. Participating providers send claims directly to your insurance carrier on your behalf. After your insurance carrier processes your claim, they will send you an Explanation of Benefits (EOB) that explains how your claim was paid and what amount, if any, you will be responsible for paying according to the terms of your plan. Non-participating Providers If you choose to receive services from a non-participating provider, you will be responsible for paying a higher coinsurance amount specified in the plan. Also, because the physician does not have a pre-negotiated contract with your insurance carrier , you will be responsible for the balance of the bills. You must then file a claim form with your insurance carrier for reimbursement at the non-network level of benefits. Your insurance carrier's  networks are comprehensive, including most recognized specialties. If there is not a particular type of specialty in the network, you may contact your insurance carrier for authorization of treatment from a non-participating provider at the in-network benefit level. Treatment from a non-participating provider will be authorized at the in-network benefit level, if the treatment and/or services are not available in network. Pre-existing Condition Limitations A preexisting condition limitation either excludes or limits coverage for conditions for which medical advice, diagnosis, care, or treatment (excluding pregnancy) was received within a specified period prior to your enrollment date. A preexisting condition limitation will not apply to members who provide proof of prior creditable coverage and did not have a lapse in coverage more than 63 days. The amount of creditable coverage will be applied to the preexisting condition limitation period specified in your PPO plan.