Upshur – Page 3 – Provider Partners Health Plans

This directory provides a list of Provider Partners Illinois Advantage Plan HMO I-SNP, Provider Partners Maryland Advantage Plan HMO I-SNP, Provider Partners Maryland Community Plan HMO I-SNP, Provider Partners Maryland Essential Plan HMO I-SNP Provider Partners Missouri Advantage Plan HMO I-SNP, Provider Partners Missouri Community Plan HMO I-SNP, Provider Partners Missouri Essential Plan HMO I-SNP Provider Partners North Carolina Advantage Plan HMO I-SNP, Provider Partners North Carolina Community Plan HMO I-SNP, Provider Partners North Carolina Essential Plan HMO I-SNP, Provider Partners Pennsylvania Advantage Plan HMO I-SNP, Provider Partners Pennsylvania Community Plan HMO I-SNP, Provider Partners Pennsylvania Essential Plan HMO I-SNP, and Provider Partners Texas Advantage Plan HMO I-SNP, current network providers and facilities. To get detailed information about your health care coverage, please see your Evidence of Coverage (EOC).

The directory covers the following counties under our plans:

For Provider Partners Illinois Advantage Plan – Our service area includes the following counties in Illinois: Cook, Dupage, Kane, Lake, McHenry, Will, and Winnebago.

For Provider Partners Indiana Advantage Plan, Provider Partners Indiana Community Plan, and Provider Partners Indiana Essential Plans- Our service area includes the following counties in Indiana: Cass, DeKalb, Delaware, Elkhart, Hamilton, Hendricks, Howard, Johnson, Madison, Marion, Marshall, Monroe, Morgan, Porter, St Joseph, Vanderburgh, Warrick, and Whitley.

For Provider Partners Maryland Advantage Plan, Provider Partners Maryland Community Plan, and Provider Partners Maryland Essential Plans– Our service area includes the following counties in Maryland: Allegany, Anne Arundel, Baltimore, Baltimore City, Caroline, Carroll, Dorchester, Frederick, Garrett, Harford, Howard, Kent, Queen Anne’s, Talbot, Washington, and Worchester.

For Provider Partners Missouri Advantage Plan, Provider Partners Missouri Community Plan, and Provider Partner Missouri Essential Plans- Our service area includes the following counties in Missouri: Audrain, Barry, Boone, Butler, Caldwell, Callaway, Camden, Cape Girardeau, Carroll, Cedar, Chariton, Christian, Clay, Clinton, Cole, Crawford, Dade, Dallas, DeKalb, Dent, Douglas, Franklin, Greene, Henry, Hickory, Howard, Iron, Jackson, Jasper, Jefferson, Laclede, Lafayette, Lawrence, Lincoln, Livingston, McDonald, Madison, Maries, Miller, Mississippi, Moniteau, Montgomery, New Madrid, Phelps, Platte, Polk, Pulaski, Ray, Reynolds, Ripley, St. Charles, St. Francois, St. Louis, St. Louis City, Saline, Scott, Stoddard, Stone, Taney, Texas, Vernon, Warren, Washington, Webster and Wright.

For Provider Partners North Carolina Advantage Plan, Provider Partners North Carolina Community Plan, and Provider Partners North Carolina Essential Plans – Our service area includes the following counties in North Carolina: Cabarrus, Davie, Forsyth, Gaston, Guilford, and Lincoln.

For Provider Partners Pennsylvania Advantage Plan, Provider Partners Pennsylvania Community Plan and Provider Partners Pennsylvania Essential Plans – Our service area includes the following counties in Pennsylvania: Allegheny, Armstrong, Beaver, Bucks, Butler, Chester, Crawford, Delaware, Fayette, Greene, Lancaster, Lawrence, Mercer, Montgomery, Philadelphia, Somerset, and Westmoreland.

For Provider Partners Texas Advantage Plan – Our service area includes the following counties in Texas: Anderson, Angelina, Bandera, Bexar, Brazos, Brown, Burnet, Cass, Chambers, Cherokee, Comanche, Concho, Cooke, Crane, Dallas, Delta, Denton, Ector, El Paso, Falls, Fannin, Fort Bend, Freestone, Goliad, Gregg, Grimes, Guadalupe, Hamilton, Harris, Henderson, Hood, Hopkins, Howard, Hutchinson, Jefferson, Jim Wells, Karnes, Kaufman, Lavaca, Limestone, Lubbock, Madison, , Maverick, McLennan, Medina, Midland, Moore, Nacogdoches, Navarro, Orange, Palo Pinto, Parker, Potter, Randall, Red River, Refugio, Robertson, Rockwall, Runnels, San Saba, Shelby, Smith, Somervell, Tarrant, Titus, , Tom Green, Tyler, Upshur, Uvalde, Val Verde, Victoria, Washington, Wichita, Williamson, Wise, and Young.

You will have to choose one of our network providers who are listed in this directory to be your Primary Care Provider (PCP). The term “PCP” will be used throughout this directory. Generally, you must get your health care services from your PCP. Provider Partners Illinois Advantage Plan HMO SNP, Provider Partners Maryland Advantage Plan HMO SNP, Provider Partners Maryland Community Plan, Provider Partners Missouri Advantage Plan HMO SNP, Provider Partners Missouri Community Plan HMO SNP, Provider Partners North Carolina Advantage Plan HMO SNP, Provider Partners North Carolina Community Plan HMO SNP, Provider Partners Pennsylvania Advantage Plan HMO SNP, Provider Partners Pennsylvania Community Plan HMO SNP and Provider Partners Texas Advantage Plan HMO SNP are an Institutional Special Needs Plan (I-SNP) Health Maintenance Organization (HMO). Since we are an HMO, it is necessary for you to select a PCP to utilize while on the plan. We do not guarantee that each provider is still accepting new members.

The “network providers” listed in this directory have agreed to provide you with your health care. You may go to any of our network providers listed in this directory. If you have been going to one network provider, you are not required to continue to go to that same provider. In some cases, you may get covered services from non-network providers. If you get a bill from a non-network provider, please submit it to Provider Partners Health Plans for processing. We can help determine how much you are responsible for paying if any.

Under certain circumstances members may obtain services from out-of-network providers. Newly eligible members who are undergoing an existing course of treatment under the care of an out-of-network provider at the time of eligibility may continue to obtain services from that provider until the member’s care is safely transferred to an in-network provider. Out-of-network providers with members under a current treatment plan must notify the health plan and request authorization of services as appropriate according to the Plan benefits. Once the health plan is notified that the member is under the care of an out-of-network provider, the provider must submit a request for authorization. All supporting clinical information must be provided to substantiate the continuation of the requested service(s). During this time existing care will not be interrupted until clinical information is reviewed for medical necessity and appropriateness. In the case where there may not be a network specialist available to the member, an out-of-network provider may be accessed at the discretion of the PCP.

Emergency care can always be obtained in or out of the service area from the nearest available provider. When in the service area you must use plan providers for urgent care. When out of the service area, urgent care may be obtained from the first available provider. In addition, when out of the service area, you can obtain dialysis treatment from any qualified dialysis provider. You must use plan providers except in emergency or urgent care situations. If you obtain routine care from out-of-network providers neither Medicare nor Provider Partners Illinois Advantage Plan HMO SNP, Provider Partners Maryland Advantage Plan HMO SNP, Provider Partners Maryland Community Plan, Provider Partners Missouri Advantage Plan HMO SNP, Provider Partners Missouri Community Plan HMO SNP, Provider Partners North Carolina Advantage Plan HMO SNP, Provider Partners North Carolina Community Plan HMO SNP, Provider Partners Pennsylvania Advantage Plan HMO SNP, Provider Partners Pennsylvania Community Plan HMO SNP and Provider Partners Texas Advantage Plan HMO SNP will be responsible for the costs.

How do you find the providers in your area?

This is a searchable online document and is updated monthly but can change at any time. First, select the plan you are searching for. Then, select how you want to search. This can be by specialty, county, state, keyword, etc. Once you select your option, prompts will guide you to the results page.

If you have questions about any of our plans or require assistance in selecting a PCP, please call our Member Service Department at 1-800-405-9681.

We are open 8:00 A.M to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30. TTY users should call 711. Or visit www.pphealthplan.com.

You may request a hard copy of Provider Partners Health Plan’s Provider Directory by calling Member Services at 800-405-9681 (TTY users call 711) 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31 and 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

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