Participants in the UVa Health Plan who live outside areas serviced by the Southern Health Provider Network will be required to use participating providers with the Coventry Health Care National Network, a national Preferred Provider Organization (PPO) network, in order to receive the highest level of benefits and pay the lowest cost-sharing amounts. This applies to enrolled National Network participants, including retirees, COBRA enrollees and dependents who are away or at school. Members who reside outside of the United States or who do not have access to sufficient providers in the National Network will be enrolled as Out-of-Area members and will not be required to use the National Network or Southern Health network.

Points to Consider When Applying for Out of Area or National Network Status

• It is the health plan member’s responsibility to submit a completed enrollment form, http://www.hrs.virginia.edu/forms/ooaenrollmentform.pdf, to the Office of University Benefits no later than the desired effective date, or the date of receipt will become the earliest effective date.
  
• Notify the Office of University Benefits if the member needs to revise/extend the effective end date that was submitted on the OOA form.
  
• Students and other National Network members remain in the National Network plan when they return home for holidays and summer break. It is important to ensure that the provider you have chosen to see when you return home is in the National Network or Southern Health network. Providers in both of these networks are paid at the in-network rate.
  
• Many college Student Health Centers offer coverage for basic preventive and minor illness care with the cost included in student fees. Check with your school concerning on-campus student health coverage. This may eliminate the need for Out-of-Area or National Network status since emergency services while out-of-area are covered when in-area status is effective.
  
• If a student enrolled in the National Network obtains services through the Student Health center that are not covered by pre-paid student fees, it is likely that the student will have a higher out-of-pocket cost. Most Student Health Centers do not participate with the National Network and, therefore, reimbursement will be at the Out-of-Network rate.
  
• Emergencies while away from home (outside the Southern Health service area) are covered as an In-Network benefit as long as Southern Health is notified within forty-eight (48) business hours, or as soon as physically possible. An emergency occurs when there is a sudden, unexpected onset of a medical or psychological condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected, by a prudent layperson who possesses an average knowledge of health and medicine, to result in:
  
  
  1. Serious jeopardy to the mental or physical health of the individual;
  2. Danger or serious impairment of the individual’s bodily functions;
  3. Serious dysfunction of any of the individual’s bodily organs; or
  4. Serious jeopardy to the health of the fetus, in the case of a pregnant woman.

Serious jeopardy occurs when there is currently an immediate safety risk that endangers or constitutes significant risk of harm to the Participant or others.

If you have further questions about Out of Area or the National Network or need help completing the form, you may contact the Office of University Benefits at 434-924-4392. Completed forms may be faxed to the Office of University Benefits at 434-924-4486 or mailed to the Office of University Benefits, 914 Emmet Street, PO Box 400127, Charlottesville, Virginia 29904-4127.

University of Virginia Health Plan
Important Guidelines for Enrollment in and Use of the National Network

• Participants in the University of Virginia (UVa) Health Plan who will reside for at least 90 days outside areas served by the Southern Health (SH) Provider Network need to elect enrollment in the National Network by completing an Out-of-Area form available at http://www.hrs.virginia.edu/forms/ooaenrollmentform.pdf You can fax the form back to the UVA Human Resources Benefits Office at 434-924-4486.
• Please note that this completed form should be submitted by the requested effective date to UHR Benefits for enrollment to begin.
• Please be aware of the end date you put on the form and let us know if it changes.
• Should you choose to see a provider who does not participate in the National Network, you will have significantly higher out-of-pocket costs and may be required to file claims. The medical claim form is available at http://www.hrs.virginia.edu/forms/uvamedclaim.pdf. The National Network Schedule of Benefits is available at http://www.hrs.virginia.edu/forms/nationalnetsched.pdf.
• If you have questions about network providers, claims, pre-authorizations, or benefits coverage, call Southern Health Customer (SH) Service at 1-888-975-9557, Monday through Friday, 8:30 a.m. - 5:30 p.m.
• Remember to inform your health care providers of your coverage in the National Network.

National Network Provider Guidelines

• The Coventry Health Care National Network (aka First Health) is the national network of medical providers (e.g physicians, hospitals, radiology centers, laboratories, urgent care, medical equipment, home health) available for use to UVa Health Plan participants enrolled in the National Network.
• You may receive medical care from any National Network or SH physician or hospital. A list of participating providers can be found on the ‘Provider Search’ section of the SH website www.southernhealth.com at the Coventry Health Care National Network link.
• You are not required to select a Network Primary Care Physician (PCP) to receive your benefits. However, a relationship with a PCP is important for wellness and general coordination of health care. Therefore, you are encouraged to establish a PCP relationship.
• You do not need a referral to see a participating medical specialist in the National Network.
• A member who is enrolled in the National Network program and who sees National Network providers or SH providers is eligible to receive in network benefits for covered services - one major point is that the member (not the provider ) is responsible for ensuring preauthorization is obtained prior to receiving services that require preauthorization. Call SH Customer Service at 1-888-975-9557 prior to accessing services to determine whether preauthorization is necessary and to check on the status of a pre-authorization for a particular service. A list of services requiring preauthorization is available at http://www.hrs.virginia.edu/forms/preauthlist.pdf.

The UVA Health Plan for prescription drugs benefits, mental health benefits, dental benefits, and vision care discount program are the same for all eligible UVA Health Plan members, whether “in area” or “out of area” status.

Here is the link to the UVA Human Resources Benefits page to review those other UVA Health Plan benefits http://www.hrs.virginia.edu/benefits.html

UVa Health Plan Guidelines

• Participants with questions about the National Network can contact the UVa Health Plan Ombudsman by email at healthplanombuds@virginia.edu or by phone at 1-434-924-4392.
• The Ombudsman is available to explain the UVa Health Plan policies and benefits coverage, investigate payment problems for claims submitted to the UVa Health Plan, listen to complaints and concerns about the health plan and facilitate the appeals process if necessary.

University of Virginia Health Plan
Important Guidelines for Enrollment in and Use of the Out of Area Coverage

• Participants in the University of Virginia (UVa) Health Plan who will reside for at least 90 days outside areas served by the Southern Health (SH) need to elect enrollment in the Out of Area plan by completing an Out of Area form available at http://www.hrs.virginia.edu/forms/ooaenrollmentform.pdf. You can fax the form back to the UVA Human Resources Benefits Office at 434-924-4486.
• Please note that this completed form should be submitted by the requested effective date to UHR Benefits for enrollment to begin.
• Please be aware of the end date you put on the form and let us know if it changes.
• The Out of Area medical schedule of benefits is available at http://www.hrs.virginia.edu/forms/ooasch.pdf.
• You do not need a referral to see a participating medical specialist in the Out of Area plan.
• A member who is enrolled in the Out of Area plan is eligible to receive in network benefits for covered services - one major point is that the member (not the provider) is responsible for ensuring preauthorization is obtained prior to receiving services that require preauthorization. Call SH Customer Service prior to accessing services to determine whether preauthorization is necessary and to check on the status of a pre-authorization for a particular service.
• For preauthorization questions, a member out of the country can directly contact Southern Health at the Charlottesville Office at (434) 975-1212 or contact them through email by using the member email via My Online services at Southern Health www.southernhealth.com. The toll free number for members within the US is on your card: (888) 975 9557.
• A list of services requiring preauthorization is available at http://www.hrs.virginia.edu/forms/preauthlist.pdf
• UVa Health plan members who are enrolled in the Out of Area plan will need to pay for medical services provided by foreign providers. The member will then need to submit claims within 12 months of the date of service to the health insurance for reimbursement.
  • Medical Claim Form - http://www.hrs.virginia.edu/forms/uvamedclaim.pdf
  • Dental Claim Form - http://www.hrs.virginia.edu/forms/5574.pdf
  • Prescription Claim Form - http://www.hrs.virginia.edu/forms/pharmacareclaimform.pdf
  • Mental Health Claim Form - http://www.hrs.virginia.edu/forms/sentaraclaim1-03-wguide.pdf
• Assistance with submission of the foreign claims to Southern Health, UCCI or PharmaCare is available by contacting the UVa Health Plan Ombudsman by email at healthplanombuds@virginia.edu or by phone at (434) 924-4392. There needs to be a bill for each claim with name of the provider, the date of service, the procedure /service received the amount of the bill and proof of payment. Please remember to submit claims within12 months of the date of service to be eligible for processing.