Notification of Payer Participation/Non-Participation
According to the Illinois Insurance Code, "When a person presents a benefits information card, a health care...provider shall make a good faith effort to inform the person if the health care provider has a participation contract with the insurer, health maintenance organization, or other entity identified on the card." Under the Fair Patient Billing Act, Pinckneyville Community Hospital must provide written notice that:
1. As a patient, you may receive separate bills for services provided by health care professionals affiliated with Pinckneyville Community Hospital.
2. Some hospital staff members may not be participating providers in the same insurance plans and networks as Pinckneyville Community Hospital.
3. You may have greater financial responsibility for services provided by health care professionals at Pinckneyville Community Hospital who are not under contract with your health care plan.
4. Any questions that you may have about your insurance coverage or benefit levels should be directed to your health care plan and/or certificate of coverage.
Listed below are those payers and insurance products with which Pinckneyville Community Hospital and the Family Medical Center have direct participation agreements:
Commercial Insurance Plans- Heathlink PPO & HMO Networks
- HealthLink Open Access I or II (Tier I/HMO)
- HealthLink Open Access III (Tier I/HMO and Tier II/PPO)
- Health Alliance
- Blue Cross Blue Shield
- Coventry PPO & HMO
- Private Healthcare System's (PCHS)
- United Healthcare
- Humana Choice Care PPO
Veteran's Community Care Program through United Healthcare
Medicare Advantage Plans- Humana Choice Care Medicare Advantage
- Coventry Medicare Advantage, Advantra
- Health Alliance Medicare Advantage
- United Healthcare Medicare Advantage
- Aetna Medicare Advantage
Managed Medicaid Plans- Blue Cross Blue Shield
- Aetna Better Health (formerly IlliniCare)
We currently DO NOT participate in any dual Medicare/Medicaid plans, often known as MMAI plans. Please see following pages for additional information.
If the payer or network identified on your insurance card is NOT listed above, we do not have a direct participation agreement with that particular insurer. Furthermore, even if your insurance plan is listed above, that is not a guarantee of in-network service. Prior to receiving any non-emergency services, you should contact your insurance plan to verify that the provider and/or physician is listed as a participating provider. Be aware that when you elect to utilize the services of a non-participating provider for anything other than emergency services or services approved by the insurer in advance, the basis of your benefit payment will be determined according to your insurance policy's "out-of-network" fee schedules which will result in greater financial responsibility to you. If you receive services here, you are STRONGLY encouraged to obtain information on out-of-pocket expenses by calling your health plan using the toll free telephone number on your insurance identification card. Independent practitioners providing services at Pinckneyville Community Hospital, including but not limited to, surgeons, radiologists, pathologists, and specialty clinic practitioners, bill for their services separately and are responsible for their own participation agreements. Independent practitioners, particularly those holding clinics in the Specialty Clinic as well as surgeons, MAY NOT be participating providers in the same networks as the hospital. If you will be receiving services from an independent practitioner, we strongly encourage you to contact your insurer for participating provider information. New practitioners to the Family Medical Center may also not be considered participating practitioners until they are approved by each individual insurer's credentialing department. Furthermore, when new agreements are added, physicians may not be approved as participating at the same time as the agreement effective date. If you are seeing a new practitioner or are covered by a plan newly added to the above list, please inquire as to the practitioner's participating status.
Pinckneyville Community Hospital is not in-network and does not accept the following insurance cards. These are health discount cards and not full insurance network plans. Patients with these insurance coverages will be set up as private pay. Patients can elect for a copy of their detailed billing statement for which they can send to the insurance plan for potential reimbursement directly to the patient for up to the eligible coverage payment limits.
At this time, Pinckneyville Community Hospital and Family Medical Center do no participate in the dual Medicare/Medicaid plans that are commonly referred to as MMAI plans. MMAI stands for Medicare Medicaid Alignment Initiative (MMAI) and is a healthcare program for people who have both Medicare and Medicaid under a single plan. Following are some sample insurance cards of these dual Medicare/Medicaid plan.
Pinckneyville Community Hospital tries to join the most common insurance plans but unfortunately cannot join every plan that may be offered. Before making insurance changes, we encourage individuals to first verify whether their hospital and physicians accept a particular insurance plan. If this particular insurance plan becomes more common in our area, participation in the plan will be taken in to consideration. If individuals have coverage with a plan for which the Hospital or Clinic are not in network, patients can elect to sign an advanced notice of non-coverage and have services provided as self-pay, can find another provider who accepts their insurance plan or see if there is opportunity to change your coverage to another plan that is accepted by the Hospital and your physician