Provider Directory

Provider Directory Disclaimer

Provider Directory Disclaimer

This directory provides a list of Provider Partners Illinois Advantage HMO I-SNP, Provider Partners Maryland Advantage HMO I-SNP, Provider Partners Maryland Community HMO I-SNP, Provider Partners Missouri Advantage HMO I-SNP, Provider Partners Missouri Community HMO I-SNP, Provider Partners North Carolina Advantage HMO I-SNP, Provider Partners North Carolina Community HMO I-SNP, Provider Partners Pennsylvania Advantage HMO I-SNP, Provider Partners Pennsylvania Community HMO I-SNP, and Provider Partners Texas Advantage 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 – Our service area includes the following county in Illinois: Cook, Dupage, Kane, Lake, McHenry, Will, and Winnebago.

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

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

For Provider Partners Pennsylvania Advantage and Provider Partners Pennsylvania Community – 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 – Our service area includes the following counties in Texas: Anderson, Angelina, Bandera, Bexar, Brazos, Brown, Burnet, Cass, Cherokee, Collingsworth, Cooke, Concho, Crane, Dallas, Delta, Denton, Ector, El Paso, Falls, Fannin, Freestone, Goliad, Gray, Gregg, Grimes, Guadalupe, Hamilton, Hardin, Harris, Henderson, Hood, Hopkins, Howard, Hutchinson, Jefferson, Jim Wells, Karnes, Kaufman, Lavaca, Limestone, Lubbock, Madison, Matagorda, Maverick, McLennan, Medina, Midland, Moore, Nacogdoches, Navarro, Orange, Palo Pinto, Parker, Potter, Randall, Red River, Refugio, Robertson, Runnels, San Saba, Shelby, Smith, Somervell, Tarrant, Titus, Trinity, Tyler, Upshur, Uvalde, Val Verde, Victoria, Witchita, 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 HMO SNP, Provider Partners Maryland Advantage HMO SNP, Provider Partners Maryland Community, Provider Partners Missouri Advantage HMO SNP, Provider Partners Missouri Community HMO SNP, Provider Partners North Carolina Advantage HMO SNP, Provider Partners North Carolina Community HMO SNP, Provider Partners Pennsylvania Advantage HMO SNP, Provider Partners Pennsylvania Community HMO SNP and Provider Partners Texas Advantage 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 HMO SNP, Provider Partners Maryland Advantage HMO SNP, Provider Partners Maryland Community, Provider Partners Missouri Advantage HMO SNP, Provider Partners Missouri Community HMO SNP, Provider Partners North Carolina Advantage HMO SNP, Provider Partners North Carolina Community HMO SNP, Provider Partners Pennsylvania Advantage HMO SNP, Provider Partners Pennsylvania Community HMO SNP and Provider Partners Texas Advantage 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.