Healthcare 101

What is CoxHealth Network?

CoxHealth Network was created as the dedicated team to bring physicians, providers, insurance companies and employer groups together for commercial insurance contracting.  As a provider network of more than 1,500 physicians and numerous hospital providers in a 20-county area, CoxHealth Network has self-funded group contracting opportunities and many commercial health insurance companies to choose from when making your health insurance buying decisions.  CoxHealth Network is dedicated to superior customer service as the liaison between employer groups, physician providers or insurance companies. We intend to do whatever it takes to build long-term relationships and healthy individuals.

What is a Third Party Administrator or TPA?

A TPA is an entity that processes and pays health care claims, based on a member's benefit plan, on behalf of a group or company. For a list of your benefits, contact your TPA. CoxHealth Network is not a TPA.

How can I obtain a premium quote (a quote for insurance coverage)?

You may contact an insurance agent or broker in your community to obtain quote for a group or individual policy. The insurance agent/broker will assess your health care needs and provide the best option for you. Cox Insurance Company is available to provide premium quotes. Their number is 417-269-4679.

Are dental services providers included in CoxHealth Network?

Our Network provides a wide-variety of medical benefits. We do not have a dental network but do have oral surgeons for medical needs. For more information regarding dental benefits, contact your employer's Human Resources/Benefits Department.

How can I change to another Primary Care Physician (PCP)?

If you have a PPO or Indemnity policy, you most likely were not required to choose a PCP. Therefore, you can change your PCP at any time you want. If you have an HMO policy, contact your health plan's member services or your employer's Human Resources/Benefits Department for requirements.

What is my responsibility as a member of a managed care health plan?

You are responsible for:

  • Presenting your insurance card each time you visit a provider
  • Knowing what co-pay and co-insurance you are responsible for paying at the time of your visit
  • Knowing your benefits based on your health plan's coverage
  • Informing the provider that you may have dual coverage through another plan (i.e. covered under spouse's plan), if applicable
  • Informing your provider's office of any changes that may affect your coverage

Claims Payment

Does CoxHealth Network pay claims?

Insurance companies/third party administrators pay claims. CoxHealth Network does not pay claims.

I feel a claim has been paid improperly. How can I resolve this issue?

Begin by calling the insurance company/third party administrator listed on your insurance card. If no resolution is reached after speaking with the insurance company/third party administrator, contact your employer's Human Resources/Benefits Department. A representative will be able to assist you.

I have received an explanation of benefits (EOB) letter from my insurance company explaining that the claim for my health care service wasn’t paid. What should I do?

The insurance company/third party administrator will be able to answer that question for you. You should be able to find their phone number at the top of the letter you received or listed under "Benefits and Eligibility" on your insurance card.

Benefits

How can I learn if a provider is a CoxHealth Network provider?

You can find this information on the CoxHealth Network web site. From the CoxHealth Network home page, click on the "Provider Search" link and type in the physician's name. If the physician appears, check the "Network Affiliation" field to see if "CoxHealth Network" appears.  If that distinction appears, your provider is a CoxHealth Network provider.  Please contact the physician's office to verify his/her current status.

If I see a doctor who isn’t listed in the Provider Directory, will my bill be paid?

If you have out-of-network benefits on your plan, the bill will be processed according to your out-of-network benefits. Contact your insurance company/third party administrator for more information. If you are unsure of who is your insurance company/third party administrator, contact your Human Resources/Benefits Department.

How much of my doctor bill will be paid by insurance?

The benefits administrator of your plan determines the amount paid by insurance. To find this information, you will need to call the number listed under "Benefits and Eligibility" on your insurance card.

What insurance benefits do I have?

Your insurance company/third party administrator determines this. To find this information, you will need to call the number listed under "Benefits and Eligibility" on your insurance card. You also can find the information in your plan document book.

Where can I find information on vision, chiropractic and mental health benefits?

Your insurance company/third party administrator has this information. Their number is listed under "Benefits and Eligibility" on your insurance card. You also can find the information in your plan document book.

Will my insurance pay for a specific procedure?

Contact your insurance company/third party administrator. You can find their number listed under "Benefits and Eligibility" on your insurance card. They will be able to tell you the specific procedures that are considered a covered benefit.

I’ve lost my insurance card. How can I get another one?

Your insurance company/third party administrator will be able to issue you a new card. You also may contact your Human Resources/Benefits Department.

I’ve received a letter from my insurance company/third party administrator stating that I need to provide more information before a procedure will be paid. What information do they need?

It’s important that you respond promptly to this request. Your insurance company/third party administrator will be able to tell you what you need to provide. You should be able to find their number at the top of the letter you received or listed under "Benefits and Eligibility" on your insurance card.

Do I need a referral to see a specific doctor?

Your insurance company/third party administrator will be able to answer that question. You can find their number listed under "Benefits and Eligibility" on your insurance card. You also can find this information in your plan document book.