Identification cards | We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 507-366-1400 in Panama, and 800-424-8196 or 312-935-3671 in the United States. You may also request replacement cards through our website: www.pcabp.com.pa. |
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Where you get covered care | You can get care from any "covered provider" or "covered facility". How much we pay - and you pay - depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less. |
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Balance Billing Protection | FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract. |
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| We consider the following to be covered providers when they perform services within the scope of their license or certification:
a licensed doctor of medicine (M.D.) or a licensed doctor of osteopathy (D.O.); a licensed specialist in his/her specialty; a licensed doctor of podiatry (D.P.M.); a licensed dentist (D.D.S. or D.M.D.); a licensed chiropractor (D.C.); a licensed registered physical, occupational, or speech therapist (R.P.T., R.O.T., or R.S.T.); a qualified clinical psychologist, clinical social worker, optometrist, nurse midwife, nurse practitioner/clinical specialist, nursing school administered clinic and nutritionists/licensed dieticians.
When we use the term doctor, we mean the following providers when the services are performed within the scope of their license or certification.
Doctor - A licensed doctor of Medicine (M.D.) or osteopathy (D.O.); a licensed specialist in his/her specialty; or, for other certain specified services covered by this Plan, a licensed dentist.
Independent Consulting Doctor - An independent consulting doctor is a specialist who:
- Is certified by the American Board of Medical Specialists in a field related to the proposed surgery;
- Is independent of the doctor who first advised the surgery;
- Does not perform the surgery for the insured person;
- Makes a personal exam of the insured person; and
- Sends the Plan a written report.
Primary Care Provider – a licensed medical doctor whose practice is devoted to internal medicine, family/general practice or pediatrics.
Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.
We list network-contracted covered providers in our network provider directory, which we update periodically, and make available on our website.
This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.
This plan provides Care Coordinators for complex conditions and can be reached at 507-366-1400 in Panama, and 800-424-8196 or 312-935-3671 in the United States for assistance. |
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| Covered facilities include:
Clinic - A place, other than a hospital, licensed to provide treatment or diagnosis and staffed by one or more doctors.
Hospice - A public or private agency or organization which administers and provides hospice care; and is:
- licensed or certified as such by the state in which it is located;
- certified (or is qualified and could be certified) to participate as such under Medicare;
- accredited as such by the Joint Commission on the Accreditation of HealthCare Organizations; or
- meets the standards established by the National Hospice Organization.
Hospital - a facility that is:
- An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations; or
- Any other institution which is operated pursuant to law under the supervision of a staff of doctors and with 24-hour-a-day nursing service, and which is primarily engaged in providing:
- General patient care and treatment of sick or injured persons through medical, diagnostic and major surgical facilities, all of which must be provided on its premises or under its control; or
- Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control or through a written agreement with a Hospital (as defined above) or with a specialized provider of those facilities; or
- In Panama, authorized by the Ministry of Health to operate as such.
In no event shall the term "Hospital" include a convalescent nursing home, or an institution or part thereof which:
- Is used principally as a convalescent facility, rest facility, or facility for the aged;
- Furnishes primarily domiciliary or custodial care, including training in the routine of daily living; or
- Is operated as a school.
Rehabilitation Facility - An institution that: (1) meets the "hospital" definition as stated; or (2) provides a program for the treatment of alcohol or drug abuse and meets one of the following requirements: (a) is affiliated with a hospital under a contractual agreement with an established patient referral system; (b) is licensed, certified or approved as an alcohol or drug abuse rehabilitation facility by the State; or (c) is accredited as such a facility by the Joint Commission on Accreditation of Healthcare Organizations.
Skilled Nursing Facility - An institution that (1) is operated pursuant to law and primarily engaged in providing the following services for patients recovering from an illness or injury: room, board and 24-hour-a-day nursing service by professional nurses; (2) is under the full-time supervision of a doctor or registered nurse (R.N.); (3) maintains adequate medical records; and (4) has the services of a doctor available under an established agreement for 24 hours a day, if not supervised by a doctor. |
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What you must do to get covered care | It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance. |
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| If you have enrolled in the Point of Service option in Panama you must select a primary care provider. Your primary care provider will provide or coordinate most of your healthcare. If you want to change your primary care provider call us in Panama at 507-366-1400. |
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| If you have enrolled in the Point of Service option in Panama, your primary care provider will refer you to a specialist for needed care. You must receive a referral form from your primary care provider and present it to the specialist for Point of Service benefits to be applicable. The specialist must request and receive authorization from AXA prior to additional consultations and/or treatment. |
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| Specialty care: If you have a chronic or disabling condition and
- lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or
- lose access to your PPO specialist because we terminate our contract with your specialist for reasons other than for cause,
you may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist and your PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days. |
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- If you are hospitalized when your enrollment begins
| We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at 507-366-1400 in Panama, and 800-424-8196 or 312-935-3671 in the United States. If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
- You are discharged, not merely moved to an alternative care center;
- The day your benefits from your former plan run out; or
- The 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment. |
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You need prior Plan approval for certain services | The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits (1) requires precertification, prior approval or a referral and (2) will result in a reduction of benefits if you do not obtain precertification, prior approval or a referral.
You must get prior approval for certain services. Failure to do so will result in us limiting our payment for outpatient services to 50% of our plan allowance and applying a $500 penalty for inpatient charges. |
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Warning: | We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis. |
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Exceptions | You do not need precertification in these cases:
- You are admitted to a hospital outside the United States or the Republic of Panama.
- You have another group health insurance policy that is the primary payor for the hospital stay.
- Medicare Part A is the primary payor for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payor and you do need precertification.
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- Inpatient hospital admission
| Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won’t change our decision on medical necessity.
In most cases, your physician or hospital will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether or not they have contacted us. |
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| You must obtain prior authorization as follows.
- All inpatient and/or outpatient surgeries (including organ/tissue transplants) must be precertified.
- For all elective (non-emergency) surgical procedures, we may require a second surgical opinion. If you fail to comply with this requirement, we will limit our payment to 50% of our Plan allowance for these surgery charges.
- For all in hospital surgical procedures not related to the original diagnosis for which you obtained precertification, we may require you to get a second surgical opinion. If you fail to comply with this requirement, we will limit our payment to 50% of our Plan allowance for these surgery charges if medical necessity can be determined.
- Growth hormone therapy (GHT) must be preauthorized.
- Durable Medical Equipment (DME).
- Gender Affirming Surgery.
- Orthopedic and prosthetic devices such as artificial limbs and eyes.
- If designated outpatient surgical procedures (see page 44 for a complete listing) are performed on an inpatient basis, we will limit our payment to 50% of our Plan allowance. However, if it is medically necessary that you be hospitalized for the surgical procedure, we will pay our regular benefits if you have precertified your admission.
- We require you to obtain precertification on both an inpatient and outpatient basis for specifically designated, non-routine diagnostic procedures that are high cost, involve high technology or that may be over-utilized. These tests include CAT scans, MRIs, Nuclear Medicine Studies (e.g. Thallium Cardiac Studies), certain Arteriographies, Genetic Studies and other similar procedures. If you fail to comply with this requirement, we will limit our payment for outpatient services to 50% of our Plan allowance and impose a $500 penalty for inpatient charges.
- All dental surgery, periodontics, endodontics require prior approval.
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How to request precertification for an admission or get prior authorization for Other services | We require both FFS and POS Plan members to precertify all admissions to evaluate the medical necessity of your proposed admission and the number of hospital days you will need.
First, you, your representative, your physician, or your hospital must call us at 507-366-1400 in Panama, and 800-424-8196 or 312-935-3671 in the United States before admission or services requiring prior authorization are rendered.
Next, provide the following information:
- enrollee's name and Plan identification number;
- patient's name, birth date, identification number and phone number;
- reason for hospitalization, proposed treatment, or surgery;
- name and phone number of admitting physician;
- name of hospital or facility; and
- number of days requested for hospital stay.
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| For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim.
If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is exginal 15-day perpected.
If we need an extension because we have not received necessary information, our notice will describe the specific information required and we will allow you or your provider up to 45 days from the receipt of the notice to provide the information. |
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| If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.
If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours from the receipt of this notice to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) theend of time frame, whichever is earlier.
We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.
You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 507-366-1400 in Panama, and 800-424-8196 or 312-935-3671 in the United States. You may also call OPM's FEHB 2 at (202) 606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 507-366-1400 in Panama, and 800-424-8196 or 312-935-3671 in the United States. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). |
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| A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.
If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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- Emergency inpatient admission
| If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. If you do not phone the Plan within two business days, penalties may apply - see Warning under Inpatient hospital admissions earlier in this Section and If your hospital stay needs to be extended below. |
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| You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.
Note: When a newborn requires definitive treatment during or after the mother's hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. |
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- If your hospital stay needs to be extended
| If your hospital stay - including for maternity care - needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days. If you remain in the hospital beyond the number of days we approved and did not get the additional days precertified, then
- For the part of the admission that was medically necessary, we will pay inpatient benefits, but
- For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.
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- If your treatment needs to be extended
| If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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If you disagree with our pre-service claim decision | If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 507-366-1400 in Panama, and 800-424-8196 or 312-935-3671 in the United States.
If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. |
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- To reconsider a non-urgent care claim
| Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to
- Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
- Ask you or your provider for more information. You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
- Write to you and maintain our denial.
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- To reconsider an urgent care claim
| In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite only the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods. |
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- To file an appeal with OPM
| After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure. |
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