Frequently Asked Questions


Q: If I have an accident, what do you need to process my claim?
Q: What is a PPO?
Q: How do I know if my doctor is a member of my PPO?
Q: If you want a specific physician added to your PPO network, who should you contact?
Q: What is COBRA?
Q: When my employment terminates, will I be able to continue my insurance coverage?
Q: What events constitute a COBRA qualifying event?
Q: What is HIPAA?
Q: What is "Usual Reasonable and Customary" (UCR), and how is this determined?
Q: What is an Explanation of Benefits?
Q: What is a co-payment?
Q: Why should I use a generic over a brand name drug?
Q: What is a Preferred Drug List?
Q: What if I am currently taking a prescription for a drug that is not on the Preferred Drug List?
Q: What if my doctor prescribes a drug that is not on the Preferred Drug List?


Q: If I have an accident, what do you need to process my claim?

We need the full accident details, including where, when and how the accident happened. We also need to know if this is related to an on the job injury. In most cases, unless a third party is involved in the accident, this is all the information we will need in order to expedite your claim. We cannot begin to process your claim until we know the details of the accident. You can print a copy of a Claim Form from this web site to fill out and mail to BMI-HealthPlans with the accident details.

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Q: What is a PPO?

PPO stands for Preferred Provider Organization. A PPO is a managed health care network of medical providers who have contracted to provide their quality services to member patients. The Plan saves money when you use participating providers so these savings are shared with you by offering better benefits than if you use a Non-PPO provider. PPO providers include physicians, hospitals, outpatient facilities and other ancillary providers. You may access your PPO Providers here as well.

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Q: How do I know if my doctor is a member of my PPO?

You may locate PPO directories several ways. Contact your HR department or reference BMI-HealthPlans online directory of PPO providers by simply locating and clicking on the PPO name on the PPO/RX Links page that matches the PPO icon that is shown on your ID card. Please remember that BMI-HealthPlans does not maintain these web sites and is not responsible for their content or accuracy. If your PPO is not listed, please refer to the provider directory that was given to you to see if your doctor is a listed provider. If you do not have a directory, you can obtain one from your Human Resources Department at work. Depending upon the print date of the provider directory, you may want to contact the PPO network directly at the number listed on the directory to verify if your doctor is still a PPO provider. You may also want to ask your doctor if they are still participating in your PPO. It is a good idea to check the status of your doctor's or hospital's participation in your PPO prior to each time you seek medical care.

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Q: If you want a specific physician added to your PPO network, who should you contact?

Please have your physician contact the PPO network listed on the identification card.

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Q: What is COBRA?

The Consolidated Omnibus Budget Resolution Act provides for a continuation of your current benefits if you should experience a loss of coverage due to a "qualifying event" such as loss of your employment.

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Q: When my employment terminates, will I be able to continue my insurance coverage?

Yes, if your Employer is subject to COBRA. All employers with more than 20 employees are subject to COBRA. If BMI-HealthPlans administers your Employer's COBRA plan, you will receive a letter from BMI-HealthPlans containing information on how to continue your coverage. When you receive this letter, indicate which dependent(s) you want continued coverage for, sign the application and enclose a check for payment. You will also receive a "Certificate of Creditable Coverage" which indicates medical coverage dates and covered members of your family. You will need to give a copy of this letter to your new employer.

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Q: What events constitute a COBRA qualifying event?

The qualifying events with respect to an employee who is a qualified beneficiary are:
  1. Termination of employment (for reasons other than the employee's gross misconduct); and
  2. Reduction in the employee's hours of employment. With respect to an employee's spouse or dependent child who is a qualified beneficiary, the qualifying events are:
    1. Termination of the employee's employment (for reasons other than the employee's gross misconduct.)
    2. Reduction in the employee's hours of employment.
    3. Death of the employee.
    4. Divorce or legal separation from the covered employee.
    5. The employee's entitlement to Medicare.
    6. The employer's commencement of a bankruptcy proceeding under Title 11 of the United States Code.
    7. The child's ceasing to be a covered dependent child under the terms of the plan.
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Q: What is HIPAA?

The Health Insurance Portability and Accountability Act, otherwise referenced to as HIPAA, was enacted on August 21, 1996. The main intent of HIPAA is to improve the portability and continuity of health care coverage in the group and individual insurance markets and group health plan coverage provided in connection with employment.

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Q: What is "Usual Reasonable and Customary" (UCR), and how is this determined?

This term refers to the designation of a charge as being the usual charge made by a physician or other provider that does not exceed the general level of charges made by other providers rendering comparable care within the same geographical area. BMI-HealthPlans utilizes a national company to provide our UCR data.

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Q: What is an Explanation of Benefits?

The Explanation of Benefits is an explanation of how your claim was processed. It will include the total charge submitted by the Provider and will identify any ineligible charges, discounts, amounts applied to the deductible and the patient responsibility. Any amounts shown as "patient responsibility" should be paid directly to the physician, hospital or other service provider. You can view and/or print this information from the online benefits link in this web site after being signed up for this feature. You can also contact the claims department at BMI-HealthPlans. (918-335-0387 or 1-800-824-5034) for an original copy.

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Q: What is a co-payment?

Many plans offer prescription drugs for a co-payment. A co-payment is typically a flat dollar amount or percentage of the cost of a prescription that you pay each time you buy medications. Most plans also offer a reduced co-payment when you purchase generic drugs instead of brand name drugs. Choosing generic drugs or from the Preferred Drug List used by your plan can reduce the amount that you pay for your prescription medications.

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Q: Why should I use a generic over a brand name drug?

As consumers, we may be suspicious of generic products, but for medications, it's a different story. A generic drug is chemically identical to its brand name counterpart. The FDA goes through the same approval process for generic medication as it does for brand name drugs. The generic drug manufacturer has to prove that the drug is the "bioequivalent" of the brand name drug and provides the same results. Generic drugs are usually sold at a price 20-80% less than the brand name product. On most plans, you have the choice to continue to use a brand name medication, but your co-payment will reflect a greater share of the cost.

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Q: What is a Preferred Drug List?

The Preferred Drug List or formulary brand names vary from plan to plan. The drugs on every plan's Preferred Drug List have been evaluated by physicians and pharmacists and determined to be the most effective for the most number of patients. Because new drugs are constantly being introduced, the Preferred Drug List is frequently reviewed and updated. If more effective or safer drugs that are reasonably priced appear on the market, they may be added to the list. By using a generic or preferred drug, you will save money over the brand, save your employer money and continue to receive the same high quality of care.

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Q: What if I am currently taking a prescription for a drug that is not on the Preferred Drug List?

If you are now taking a brand name medication not on your Preferred Drug List, you may choose to continue the drug at a higher co-payment, or you may ask your physician to change your medication to a generic or preferred drug from the list. Either you or your pharmacist can arrange this with a simple phone call to your physician.

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Q: What if my doctor prescribes a drug that is not on the Preferred Drug List?

We suggest that you carry a Preferred Drug List with you when you see your doctors so that he or she may prescribe drugs from the list whenever possible. It may be necessary for your treatment that you use the brand name drug, in which case you will be responsible for sharing in the cost of the drug by paying a high co-payment. However, if a non-preferred or generic drug is available, your in-network pharmacist may contact your doctor to see if you can be switched to the generic or formulary.

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