Here
are answers to some of the most frequently
asked questions from Members about FirstCarolinaCare:
How
can I make the most of my FirstCarolinaCare
health 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.
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Why
do I need a Primary Care Provider (PCP)?
Your
PCP should coordinate all of your health care.
Your PCP arranges for all necessary specialty
care and keeps all of your medical records
in one place. You benefit from this relationship
because your PCP:
- Becomes
familiar with your medical history and
gets to know you better; and
- Provides
or recommends the most appropriate care
for you.
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How
is FirstCarolinaCare different from other
HMO programs?
FirstCarolinaCare
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
has local physicians participating on our
committees and as members of the FirstCarolinaCare
Board.
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What
does “out-of-network” mean?
With
FirstCarolinaCare, 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.
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How
do my benefits work when I don’t
get care from a participating provider?
Most
of the plans that FirstCarolinaCare offers
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.
(Claim forms are available from your employer
or from FCC.) FirstCarolinaCare will then
reimburse you up to our maximum allowable
payment.
FirstCarolinaCare
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.
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What
does “open access” mean?
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.
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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.
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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.
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What
is the Nurse Helpline?
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.
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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
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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.
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Any
questions?
If
you have any questions about the coverage
offered through FirstCarolinaCare, please
call our office at (910) 715-5270.
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