Broker Services Menu
Search
Here are answers to some of the most frequently asked questions from Members about FirstCarolinaCare:
How can I make the most of my health insurance benefits?
How is FirstCarolinaCare Insurance Company different from other HMO programs?
What does “out-of-network” mean?
How do my benefits work when I don’t get care from a participating provider?
What do I do if I need to be hospitalized?
Do I have to file my own claims for reimbursement?
How do I know if I should go to the ER?
How can I avoid a trip to the ER?
How can I make the most of my health insurance benefits?
To receive the most from your plan you should familiarize yourself with your Certificate of Coverage and your Schedule of Medical Benefits. You should use participating providers for your care (which minimizes your share of the cost) and when appropriate you should see your Primary Care Provider (PCP) and use your PCP to coordinate your health care needs.
How is FirstCarolinaCare different from other HMO programs?
FirstCarolinaCare Insurance Company is a plan with options. It gives you the freedom to choose your provider each time you need care for a covered service. You can see any participating provider in the network at your in-network benefits. You may also choose to see a provider outside the FirstCarolinaCare network at your out-of-network benefits.
FirstCarolinaCare works in partnership with local physicians for all our medical management. Also, FirstCarolinaCare Insurance Company has local physicians participating on our committees and as members of the FirstCarolinaCare Board.
What does “out-of-network” mean?
With FirstCarolinaCare Insurance Company, you have the option to use a provider that is not in our network and still receive benefits for most covered services. When you elect to see a provider out of our network you are using your “out-of-network” benefits. Your out-of-pocket costs are usually higher with your “out-of-network” benefits.
How do my benefits work when I don’t get care from a participating provider?
Most of the plans that we offer are Point of Service plans. This means you have the option of going to either a participating provider (in network) or going to a non-participating provider (out-of-network). The choice is yours.
When you see a non-participating provider you have elected to use your out of network benefits. With out of network benefits your out of pocket costs are higher. Your deductible, coinsurance and out-of-pocket maximum are greater than with your in network benefits.
A non-participating provider may ask you to pay your bill in full when you receive services. If this is the case, you should pay your bill and then file a claim with FirstCarolinaCare Insurance Company. (Claim forms are available from your employer or from FCCIC.) We will then reimburse you up to our maximum allowable payment.
FirstCarolinaCare Insurance Company will reimburse non-participating providers up to our maximum allowable payment. The difference between billed charges and our maximum allowable payment will be your responsibility.
When a plan is called “open access” it means that you can go to any participating provider at in-network benefits without first having to get a referral from your Primary Care Provider or you may go to any non-participating provider at out of network benefits without having to get a referral first.
What do I do if I need to be hospitalized?
Inpatient hospital stays require precertification prior to admission. Your provider that is admitting you to the hospital should complete the precertification process for you. However, you are encouraged to contact Member Services at 800-811-3298 to verify that your precertification has been completed prior to your hospital stay.
Do I have to file my own claims for reimbursement?
Not with FirstCarolinaCare participating providers. If you see a non-participating provider, the provider may or may not require payment at the time you receive services. Unlike participating providers, non-participating providers are not required to file claims for FirstCarolinaCare members.
The Nurse Helpline is a service provided for you by FirstCarolinaCare to help advise you if you have questions regarding health care services such as whether you need to go to the Emergency Department or should wait to see your provider. The Nurse Helpline is available 24 hours a day, 7 days a week, 365 days a year. In addition, the Nurse Helpline has an audio medical library available which allows you to choose topics and listen to information over the telephone. You can access the Nurse Helpline at 800-336-2121.
How do I know if I should go to the ER?
You should go to the nearest Emergency Department if you believe you are placing your health in serious jeopardy by not going. Examples of when to go to the ED are:
- Chest pain
- Uncontrolled bleeding
- Poisoning
- Loss of consciousness
- Severe shortness of breath
- Major trauma or injury
How can I avoid a trip to the ER?
At your next visit to your provider, ask how you should contact him or her after hours and what information to have available when you talk to him or her. Also ask your provider what to do if you need to be “fit in” to his or her appointment schedule on an urgent basis.
If you feel you need care but are unsure whether to go to the ER, contact your provider for advice. Your provider may be able to assist you over the telephone. You may also contact the Nurse Helpline for assistance in determining if you need to go to the ER.
Any questions?
If you have any questions about the coverage offered through FirstCarolinaCare Insurance Company, Inc., please call our office at (910) 715-8100.