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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 or are accepted Medicare Advantage Private Fee For Service (PFFS) plans:

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
Mutliplan
UMWA
United Healthcare
Three Rivers Provider Network
Aetna
Humana Choice Care PPO
CIGNA
HSTechnology Solutions, Egyptian Area School Employee Benefit Trust

Medicare Advantage Plans

Humana Choice Care Medicare Advantage
Coventry Medicare Advantage, Advantra
Health Alliance Medicare Advantage
Humana Gold Choice PFFS
United Healthcare Medicare Advantage
Aetna Medicare Advantage

Managed Medicaid Plans

Blue Cross Blue Shield
IlliniCare
Meridian
Molina
Harmony

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.

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