FOR PROVIDERS
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Verify Eligibility
To verify eligibility, exclusions, and covered services, please call our Benefit Advocacy team.
Monday - Friday 7am-6pm MT
prior authorization
Our plans do not currently require prior authorization.
However, we encourage you to contact us for detailed information about what services are covered under your patient's plan.
Planstin's Minimum Essential Coverage (MEC) plans cover preventive care and basic services. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's plan documents at the time of service. Listed below is an example of covered benefits for some of our plans to give you an idea of how a claim from your office might be paid.
MEC PLAN INFORMATION
FOR PROVIDERS
This information is for example purposes and does not guarantee eligibility or payment.
Service | Basic Plan | Copay Plan | HSA Plan |
---|---|---|---|
Preventive Care | In Network Only | Covered | Covered |
Office Visits | Not Covered | Subject to Plan Limits | Subject to Deductible |
Specialist Visits | Not Covered | Subject to Plan Limits | Subject to Deductible |
Lab Work | Not Covered | Subject to Plan Limits | Subject to Deductible |
Imaging (X-ray, CT, MRI) | Not Covered | Subject to Plan Limits | Not Covered |
Urgent Care | Not Covered | Subject to Plan Limits | Not Covered |
ER | Not Covered | Not Covered | Not Covered |
In-Office Procedure | Not Covered | Not Covered | Not Covered |
Maternity | Not Covered | Not Covered | Not Covered |
Genetic Testing | Not Covered | Not Covered | Not Covered |
TIMELY FILING DEADLINE = 90 DAYS
CLAIMS
FIRST CLASS MAIL
Planstin (SDS)
PO Box 21747
Eagan, MN 55121
ELECTRONIC
Payer ID
65241
NETWORK
We use the MultiPlan/PHCS Specific Services network.
IN NETWORK
OUT OF NETWORK
Most, but not all, MEC plans use reference-based pricing (RBP) for out-of-network claims for covered services.
APPEALS
Please include the following information in your written request:
- Member Name & Date of Birth
- Member ID & Group Number
- Claim Number
- Date of Service
- Name of Provider
- Reason for appeal
A provider, member, or their authorized representative has 180 days following receipt of an Adverse Benefit Determination within which to request a Standard Internal Appeal. You may request an appeal by sending a written request to the following address:
Planstin Administration
ATTN: Claims/Appeals
1506 S. Silicon Way, Suite 2B
St. George, UT 84770
All Comments, documents, records, and other information submitted and relating to the claim will be reviewed without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. The appeal will be conducted by an appropriately named fiduciary of the plan who is neither the individual who made the Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of such individual. The named fiduciary will conduct a completely new review, not considering the initial determination.
INDEPENDENT EXTERNAL REVIEW
If you still disagree with our decision and all the plan's internal appeal processes have been exhausted as outlined in the member's plan documents, you are entitled to request an Independent External Review of our decision.
You or your authorized representative must file the request within
4 months after the date of receipt of a notice of an Adverse Benefit Determination or Final Internal Adverse Benefit Determination.
EXPEDITED APPEALS
If your patient's situation meets the definition of "urgent" under the law, you may ask for and Expedited Appeal. If you, as their healthcare provider, believe that the patient's condition could seriously jeopardize their life, health, or ability to regain maximum function or would subject them to severe pain that cannot be adequately managed without care of treatment by waiting up to 30 calendar days for a decision, you may ask for an Expedited Appeal.
Expedited Appeals may be requested in writing or by calling our Benefit Advocacy team at 888-920-7526. If you make a request in writing, see the mailing address and information requirements above.
We will respond to requests for an Expedited Appeal within 72 hours from the date we receive the request.
