Apache County Medical Benefits
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Our clients’ interests are our main priority, and we commit to always working:
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With a constant strive for excellence
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Through CHS from Blue Cross Blue Shield of Arizona (BCBSAZ), you have access to BCBSAZ’s provider networks. More than 100 employer groups have chosen CHS to give their approximately 300,000 participants access to BCBSAZ-contracted doctors, hospitals and other healthcare providers. We are committed to giving you a best-in-class network; one of the largest in Arizona — 20,000-plus and counting.
For quick access, please add this website to your favorites in your web browser. Access the links at the right for more perks and convenience.
BCBSAZ provides network access only. For questions regarding your coverage, refer to your health plan benefit book or call the customer service number on your health plan ID card.
What is a Preferred Provider Organization (PPO)?
A PPO plan generally offers two (2) levels of coverage – in-network and out-of-network. The “in-network” level of coverage is applicable when you utilize the services of the contracted PPO network of medical providers. AZLGEBT has contracted with Blue Cross Blue Shield of Arizona (BCBSAZ) as its PPO network of providers for both its PPO and High Deductible Health Plan (HDHP) Medical benefit plan offerings. The “in-network” benefits apply when a provider that is contracted with BCBSAZ is utilized for care or treatment. The “out-of-network” benefits are substantially lower than the “in-network” benefits, and therefore utilization of “out-of-network” providers will increase your out-of-pocket costs for medical care and treatment.
What is a PPO Plan?
A PPO is a benefit plan offering that typically includes a combination of a deductible, co-payments for certain services and an annual out of pocket maximum.
What is a High Deductible Health Plan (HDHP)?
An HDHP is a benefit plan offering that typically includes one larger deductible that applies to both Medical and prescription drugs and under which the plan participant pays all covered expenses out of pocket until the deductible and/or out of pocket maximum is met.
What is a Deductible?
A deductible is the amount of medical expenses you are responsible for paying before your insurance starts paying benefits. The deductible amount varies depending on whether you are covered under the Preferred Provider Organization (PPO) or High Deductible Health Plan (HDHP). Deductible amounts can be found in the applicable AZLGEBT Summary Plan Description (SPD) booklet, which is available under the Medical Plan Resources tab to your right on this web-site.
What is an out-of-pocket maximum?
The out-of-pocket maximum is an annual dollar amount, including deductibles, co-insurance, co-pays and precertification penalties after which a plan begins to pay 100% of covered in-network expenses.
What is a co-payment?
A co-payment is a fixed-dollar amount that you are responsible for paying for a particular medical service. Co-payments are only found under the AZLGEBT PPO plan. Co-payment services generally do not require the satisfaction of a deductible before payment can be made. AZLGEBT co-pay amounts can be found in the PPO Summary Plan Description (SPD) booklet, which is available under the Medical Plan Resources tab to your right on this web-site.
Do my co-payments apply toward my out-of-pocket maximum?
Do I have to choose a Primary Care Physician (PCP) under the AZLGEBT medical benefit plan?
No. The AZLGEBT medical plan does not require the utilization of a primary care physician. At the time you need a medical service you determine which type of provider, PCP or specialist, is most appropriate for the condition treated.
What does "usual, customary, and reasonable (UCR)" mean?
This is the average cost a medical provider charges for services in a given geographical area. All out-of-network provider services are payable based upon UCR.
What is coordination of benefits?
When a person is covered by more than one benefit plan (for example, a child who is covered by both parents’ programs), which is known as dual coverage, the two sets of benefits are coordinated so that no more than 100 percent of the total covered expense is paid.
What is an Explanation of Benefits (EOB)?
An EOB is a statement which lists the codes of the procedures performed, along with the date of service, amount billed, discount amount (if any), and the amounts payable by the AZLGEBT and the patient.
What is Case Management?
In certain complex medical situations where many different doctors and/or treatments may be needed, case management may become necessary. A nurse case manager from American Health Group (AHG) will be assigned to work with the patient, the family, the Physician and the claims payor to coordinate an effective treatment plan.
Do I have to get authorization, or a referral, for any services?
The medical benefit plan does require pre-certification of certain services. This program is designed as a cost containment measure through a company called American Health Group (AHG) to maximize the Plan benefits and reduce unnecessary hospitalizations, surgical procedures, diagnostic and other services. Failure to comply with the pre-certification requirements may result in a twenty percent (20%) penalty, or may disqualify the Covered Person for benefits. It is always up to you, and the physician you choose, to determine what services you need and who will provide your care, regardless of what this Plan will pay for. Once a pre-certification is received, it is valid for ninety (90) days.
IMPORTANT: Pre-certification of a procedure does not guarantee benefits. All benefit payments are determined by Administrative Enterprises, Inc. in accordance with the provisions of this Plan.
For more information or to pre-certify, call AHG at 800.847.7605
Medical Plan Resources
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