Member Administration

Member Identification Cards

The cards shown below are samples of member identification (ID) cards for Premier Health Plan.

Premier Health Employee Plan

Premier Health Employee Plan 2019

Premier Health Employee Plan HSA

Premier Health Employee Plan HSA 2019

Provider and Member Rights and Responsibilities

Premier Health Group recognizes that healthcare providers have rights and responsibilities related to their work with members, other healthcare providers and Premier Health Plan. These provider rights and responsibilities can be found in the rights, roles and responsibilities section of the Provider Standards and Procedures.

Premier Health Plan pays claims and provides administrative support on behalf of Premier Health Group.

All members have the following core rights and responsibilities:

  • To receive information about the organization, its services, its practitioners/providers and members’ rights and responsibilities
  • To receive written notification (paper or electronic) about how to obtain language assistance and information in alternate formats, if needed. Language assistance includes either bilingual service (i.e., service provided directly in the member’s preferred language) or oral interpretation, and documents (either created or translated) available in the member’s preferred language or in an alternate language such as Braille. 
  • To be treated with respect and recognition of their dignity and right to privacy
  • To participate with practitioners in making decisions about their health care
  • To have a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage
  • To voice complaints or appeals about the organization or the care it provides
  • To make recommendations regarding the organization’s members’ rights and responsibilities policies
  • To supply information (to the extent possible) that the organization and its practitioners/providers need in order to provide care
  • To follow plans and instructions for care that they have agreed on with their practitioners/providers
  • To understand their health problems and participate in developing mutually agreed-upon treatment goals to the degree possible

Identifying Members and Verifying Eligibility

Providers may identify members of Premier Health Plan and verify member eligibility through several means:

Member Identification Card

Each member receives an identification (ID) card with a unique member identification number. Use of a member’s ID card by another person is insurance fraud and is grounds for the member’s termination from Premier Health Plan.

Enrollment forms for newborns and adopted children must be submitted within the first 31 days of life or placement. The child will receive a member ID card within 14 days after Premier Health Plan receives the enrollment form.

Online

Providers can verify eligibility by going to the provider portal at Provider OnLine. This website requires an initial registration to obtain a user ID and password. To view information about an eligible member, providers need the member ID number. The database then reveals the member’s benefits, including riders (additional benefits beyond basic coverage) and the effective date.To find out more about how to use the provider portal to verify eligibility, call the Web Support line at (855) 222-1043(855) 222-1043 from 8:00 am to 5:00 pm, Monday through Friday.

Provider Services

To verify whether a member’s ID card is valid, call Provider Services at (855) 514-3678(855) 514-3678 from 8:00 am to 5:00 pm, Monday through Friday.

Verification of Eligibility

Checking the member eligibility report or verifying a member’s eligibility does not constitute prior authorization or guarantee claim payment, nor does it confirm benefits or exclusions.

Updating Coordination of Benefits (COB) Information

Providers are asked to notify Premier Health Plan when they determine that coordination of benefits or other insurance coverage information for a member is missing or incorrect. They should contact Provider Services at (855) 514-3678(855) 514-3678 from 8:00 am to 5:00 pm, Monday through Friday.

To assist with timely and accurate processing of COB claims and minimize adjustments and overpayment recoveries, Premier Health Plan requires the following information:

  1. Insured ID Number
  2. Insured name
  3. Subscriber name
  4. Relationship to member
  5. Other insurance name
  6. Other insurance phone
  7. Other insurance address
  8. Effective date of coverage
  9. Term date of coverage, if applicable
  10. Type of coverage (e.g., medical, dental, auto insurance, hospital only, vision, workers’ compensation, major medical, prescription, or supplemental)

Determining Primary Insurance Coverage

If a member is covered under two group health plans, one as the employee and the other as the spouse of an employee, the group health plan covering the member as a subscriber or a retiree is primary. The group health plan covering the member as a dependent is secondary.

If a member is a subscriber on more than one group health plan, the plan that has been active the longest is the primary health insurance carrier.

If a woman has a baby, the newborn is covered under the mother’s benefits using the mother’s ID number for the first 31 days of life. If the mother does not have insurance, the baby is covered under the father’s benefits, using the father’s ID number, for the same period. For coverage to continue without a lapse beyond this initial period, the Premier Health Plan subscriber (the mother or the father) must add the newborn within the first 31 days of life by submitting a completed enrollment form to the subscriber’s employer, if applicable. For the first 31 days, if the newborn is covered under both parents, other coordination of benefits rules may apply.

If a child is adopted, the child is covered automatically from the due date of legal placement for 31 days. For coverage to continue without a lapse beyond this initial period, the Premier Health Plan subscriber (the mother or the father) must add the child within the first 31 days of life by submitting a completed enrollment form.

If a child has dual coverage from both parents who are not legally separated or divorced, the child’s primary insurance carrier is the parent or guardian whose birth date falls earlier in the calendar year. (This is known as the “birthday rule’’.)

If a child has dual coverage from both parents and the parents are divorced or separated, the child’s primary insurance carrier is the plan of the parent who has custody of the child or as indicated by court order. The secondary insurance carrier would be the plan of the spouse of the parent with custody. The tertiary insurance carrier would be the plan of the parent who does not have custody. The quaternary insurance carrier would be the plan of the spouse of the parent without custody.

Court decree exception. If a court decree makes the non-custodial parent responsible for the child’s health care or for providing health insurance, the non-custodial parent’s plan is primary.

Joint custody situations. If a court decree awards joint custody without specifying that one parent has the responsibility to provide healthcare coverage, the birthday rule is followed. (Coverage is through the parent or guardian whose birth date falls earlier in the calendar year.)

If a member is laid off or retired, the plan that covers a person as an employee (or that employee’s dependent) who is neither laid off nor retired is primary.

If a member has Premier Health Plan as secondary insurance and the primary insurance carrier authorizes coverage for a service or procedure for which Premier Health Plan requires prior authorization, then Premier Health Plan authorizations/PCP referrals are not required. If the primary carrier authorized but did not pay for the service, the provider must appeal with the primary carrier. The provider must comply with all primary insurance carrier requirements for the claim to be considered by Premier Health Plan as the secondary carrier

If a Premier Health Plan member is age 65 or older and is covered through current employment or a spouse’s current employment and also has Medicare coverage, Medicare is primary if the employer has fewer than 20 employees. Premier Health Plan is primary if the employer has 20 or more employees. Different rules may apply for certain multi-employer plans.

If a Premier Health Plan member has Medicare due to a disability, is under age 65, and also has coverage through current employment or a family member’s current employment, Medicare is primary if the employer has fewer than 100 employees and is not part of a multi-employer plan where any one employer has more than 100 employees. Premier Health Plan is primary if the employer has 100 or more employees.

If a Premier Health Plan member is also covered under Medicare because of end-stage renal disease (ESRD), Premier Health Plan is primary for the first 30 months of eligibility or entitlement to Medicare. Medicare is primary following a 30-month coordination period with a commercial health plan.

If a Premier Health Plan member is covered under workers’ compensation because of a job-related illness or injury, workers' compensation is primary for all workers' compensation-related services. 

If a Premier Health Plan member has been in an accident where no fault or liability insurance is involved, no fault or liability insurance is primary for all accident-related services.

Selecting or Changing a Primary Care Provider

Selecting a Primary Care Physician (PCP)

Premier Health Plan members are encouraged to select a PCP. If a member does not select a PCP, Premier Health Group (the provider network for Premier Health Plan) is happy to help a member select one. Premier Health Plan members may call Member Services for assistance.