MedCost, LLC Patients & Consumers FAQs

	1.	Who is MedCost?
	2.	How can I get MedCost insurance?
	3.	When should I call MedCost and when should I call my insurance company?
	4.	Does MedCost pay insurance claims?
	5.	Who pays my claims?
	6.	Who do I contact for the status of MedCost claims?
	7.	Why do claims come to MedCost?
	8.	Why is the MedCost phone number on my insurance card if you are not the insurance company?
	9.	What geographical areas does the MedCost network cover?
	10.	How do I verify whether a provider is in the MedCost network?
	11.	If a practice is listed in the MedCost Provider Directory or on the MedCost Web site are all of the providers in the practice in-network?
	12.	Do you have chiropractors in your network? What about dentists and oral surgeons?
	13.	Is a MedCost patient entitled to receive the MedCost discount for non-covered services?
	14.	What do my benefits cover? What is my co-payment?
	15.	Do I need a referral?
	16.	Can MedCost help me with pharmacy issues?
	17.	Do you cover things like glasses and braces?
	18.	Is precertification required? What number do I call for precertification?
	19.	Does certification mean that the claim for the requested service will be paid?
	20.	What is my recourse if there is noncertification?
	21.	What does MedCost require to complete a review request?
	22.	What credentials does MedCost health management have?
	23.	What are your physician consultant credentials?
	24.	What is case management?
	25.	Is MedCost HIPAA compliant?



	1.	Who is MedCost?
		MedCost is the leading Preferred Provider Organization (PPO) in the Carolinas. We work alongside your insurance company to offer you an extensive network of "preferred" providers who provide cost-effective healthcare services.
	2.	How can I get MedCost insurance?
		MedCost is not an insurance company. However, we can provide you with a list of contracted insurance carriers that work with MedCost. Click Here for the list.
	3.	When should I call MedCost and when should I call my insurance company?
		Contact the insurance company when you need to know: • Will the insurance company cover this service? • How much will the insurance company pay for this service? • Has the claim been paid yet? Contact MedCost when you need to know: • Does this provider currently participate in the MedCost network?
	4.	Does MedCost pay insurance claims?
	5.	Who pays my claims?
		Payment is issued by a third party administrator or insurance company. Payment is not issued by MedCost. MedCost is a Preferred Provider Organization (PPO) and does not issue payment on claims. The entity issuing payment for medical claims should be indicated on your insurance identification card.
	6.	Who do I contact for the status of MedCost claims?
		MedCost is not an insurance company and therefore does not pay claims. We provide the network of doctors and hospitals. When you have questions about the payment of your claims you please contact your insurance company.
	7.	Why do claims come to MedCost?
		MedCost negotiates with selected physicians, hospitals, and facilities to arrange reduced fees for a broad range of medical services. MedCost receives claims from our network providers, reprices the claims to these lower negotiated rates, then forwards the claims to the insurance company for payment.
	8.	Why is the MedCost phone number on my insurance card if you are not the insurance company?
		Since MedCost provides a network of "preferred" providers, we provide our phone number because you may need to call us to see if your doctor or hospital participates in the MedCost network.
	9.	What geographical areas does the MedCost network cover?
		MedCost’s network of providers is located primarily in North and South Carolina.
	10.	How do I verify whether a provider is in the MedCost network?
		While you’re on our Web site you can easily search our online directory of in-network providers. This provider database is updated monthly. Click here to access our online provider directory. You can also verify participation by calling MedCost’s Customer Service Contact Center at 800-824-7406.
	11.	If a practice is listed in the MedCost Provider Directory or on the MedCost Web site are all of the providers in the practice in-network?
		Although a physician practice is listed as a participating provider, not every physician in that practice may be considered a participating MedCost Preferred provider. When scheduling an appointment at a physician’s office, hospital, or facility, it is important to verify that the provider you wish to see is currently participating in the MedCost Preferred network.
	12.	Do you have chiropractors in your network? What about dentists and oral surgeons?
		MedCost has a full network of chiropractic providers, contracted through Chiropractic Network of the Carolinas. We do not contract with dentists and oral surgeons. The services of these providers would fall under the benefit provisions of your individual dental coverage. For more information about coverage for dentists and oral surgeons, please contact your insurance company.
	13.	Is a MedCost patient entitled to receive the MedCost discount for non-covered services?
		Some participating MedCost Preferred providers will extend discounted rates for services not covered by your health plan. Ask your health care provider if the MedCost discount will be honored.
	14.	What do my benefits cover? What is my co-payment?
		Because MedCost is not an insurance company we are unable to answer questions about benefits, eligibility, or claim payment issues. Please contact your insurance company for this information. Their telephone number is on your insurance card. Some cards also list the co-payment amount.
	15.	Do I need a referral?
		Your primary care physician will determine when you need specialty care and can help you select a specialist when you need one. No referral form is necessary for specialty care. With MedCost Preferred you also have the option to choose specialty care without going to your primary care physician.
	16.	Can MedCost help me with pharmacy issues?
		Since MedCost does not have a network of pharmacies, we recommend that you contact your insurance company to inquire about pharmacy benefits.
	17.	Do you cover things like glasses and braces?
		MedCost does not have information about the specific benefits of your insurance plan. Your insurance company can answer questions about your coverage. The telephone number is on your insurance ID card.
	18.	Is precertification required? What number do I call for precertification?
		Certification requirements are stated on the insurance card along with the number to call for precertification.
	19.	Does certification mean that the claim for the requested service will be paid?
		Certification is not a guarantee of payment. The certification process confirms the medical necessity of the service. It does not confirm the member eligibility or coverage for the service. All questions of eligibility and coverage for the requested service should be confirmed by contacting the insurance company.
	20.	What is my recourse if there is noncertification?
		An appeals process is available when a service has been noncertified for a medical necessity reason. Please contact the pre-certification number listed on your insurance card to initiate this process or follow the instructions on your certification notice. You are encouraged to send complete information and medical records regarding the noncertified period. All information received will be reviewed and a determination will be made. A written notification of the decision will be sent to the patient, providers, and insurance company.
	21.	What does MedCost require to complete a review request?
		MedCost will need the following information to initiate a certification: • Company name and policy ID (something other than a Social Security number) • Inpatient admission or outpatient procedure • Patient name • Patient date of birth • Is the patient the employee or a dependent? • The name of the employee • The Social Security number of the employee • Address of the employee • Is this primary or secondary insurance? • Name and phone number of the admitting physician • The date of admission or procedure After collecting this information a registered nurse will contact a medical source to obtain medical information about this service.
	22.	What credentials does MedCost health management have?
		MedCost health management programs are accredited by URAC. MedCost is also accredited under URAC provider credentialing standards.
	23.	What are your physician consultant credentials?
		All MedCost consulting physicians are board certified in their various specialties and are in active practice.
	24.	What is case management?
		Case management is a program that allows for early intervention and management of cases involving serious or catastrophic injuries or illnesses. Case managers are registered nurses who work with the patient, the providers and the claim administrator to ensure that the patient is receiving the right level of care at the right time. Case managers help to make the most efficient use of health plan benefits over the course of long-term treatment.
	25	Is MedCost HIPAA compliant?
		MedCost is fully compliant with all of the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to date.