Frequently Asked Questions

Click on one of the links below to learn more about your Employee Health Plan coverage for your state.

California

Oregon

All stated excluding CA and OR

California Associates

Coverage

Q: What is my coverage?
A: For associates living in California, we have partnered with Incentive Health to build an expansive network that combines Adventist Health facilities and providers with the Incentive Health Provider Access Solution. The Incentive Health Provider Access Solution is built specifically to prioritize first class care at our facilities. Additionally, the California Foundation for Medical Care (CFMC), one of California’s largest networks, will be replacing our current Blue Shield network for professional services.

Incentive Health Provider Access Solution coverage

Tier One: Adventist Health and UC Davis Health for professional and facility.

  • 100% coverage: Professional and facility
  • $20 copay: Provider office visits

Tier Two: The California Foundation for Medical Care (CFMC) will be replacing our current Blue Shield network for professional services. CFMC is one of California’s largest networks.

  • 80% coverage: Professional
  • $30 copay: Provider office visits

Out of Network coverage in California

Tier Three: Out of network coverage has been added to minimize any disruption in the transition from Blue Shield providers to CFMC providers.

  • 80%*coverage: Out of network facility

* Prior Authorization required for any non-emergent facility admissions. Please refer to the plan description for a list of services that require prior authorization.

  • 60% coverage: Out of network professional
  • $30 copay: Provider office visits

*If traveling outside of California, utilize the First Health PPO network. No out of network coverage available for California associates traveling outside of California.

How to find a provider

Q: How do I find a provider?
A:
To find a provider visit AdventistHealth.org/EmployeeHealthPlan and select Find a Provider from the Member menu dropdown.

Tier One providers
To find a provider in Tier One, the provider must meet one of the following criteria:

Tier Two providers
To find a provider in Tier Two providers must meet the following criteria:

Tier Three providers
To find a provider in Tier Three providers must meet the following criteria:

*If traveling outside of California, utilize the First Health PPO network. No out-of-network coverage available for California associates traveling outside of California.

Loma Linda Medical Center and Loma Linda Medical Center-Murrieta are considered Adventist Health facilities for medical benefits purposes.

Q: What if my provider isn’t part of the new Incentive Health Provider Access Solution?

A: You can check by visiting the Incentive Health Provider Access Solution. If your provider is not listed on Tier One or Tier Two, you can ask your provider to join Incentive Health by contacting our provider relations department by email providerrelations@incentivehealth.org or by phone (833) 796-0071.

You can also nominate your provider by clicking on the “Nominate a Provider” tab on the Incentive Health website.


Utilizing HST’s Value Based Payments for Tier Three Out-Of-Network Coverage

Q: My provider isn’t in Tier One or Tier Two. How do I use the Tier Three Out-Of-Network Coverage for California members?

A: Adventist Health Employee Health Plan members in California have Tier Three out-of-network coverage through HST. The information below explains how HST works for you with value based payments (VBP).

Q: What is VBP?

A: Value Based Payments (VBP) establish prices for the services offered by facilities under a health plan. VBP works by reimbursing facilities based on the value and quality of care. The process is fully transparent and based on costs, so the end result is a price that is fair to both the facility and the patient. That price is based on Medicare plus a percentage.

Q: What does this mean for you?

A: Value Based Payments (VBP) is revolutionizing the way we purchase healthcare by bringing transparency and affordability to the consumer. Members enjoy lower out-of-pocket costs at facilities, reflected in coinsurance payments, and a greater ability to deal with unexpected medical costs.

Physicians

A Physician’s PPO network will still be utilized for physician and other non-hospital provided services. Your out-of-pocket expenses will be less when you see a physician within the network.

Below are a few examples of covered services:

  • Primary Care Physician
  • Chiropractor
  • OB/GYN
  • Specialist
  • Dermatologist
  • Therapist

Hospitals

For inpatient and outpatient services, your Plan is open access, allowing you to choose any facility. VBP determines a fair price by looking at Medicare and cost for a specific service. VBP ensures that you are not over paying for your medical services.

Below are few examples of covered services:

  • Hospitals
  • Urgent Care facilities
  • Surgery centers
  • Emergency rooms

Value based payments (VBP) frequently asked questions

1. How does my VBP Plan work?

Your VBP Plan works by paying providers a percentage above what Medicare would pay. This establishes a Reasonable and Allowed price that is beneficial for you and your family, the Plan and the provider.

2. Can I still go to my provider if they do not accept VBP?

Yes. You may still go to your provider but your out-of-pocket expensemay be higher.

3. Are facilities familiar with VBP?

Yes, facilities are required to file their costs and pricing information with the Center for Medicare & Medicaid Services (CMS) and to comply with numerous states pricing transparency requirements.

4. What if my provider does not accept VBP?

First, call your provider directly to make sure they do not accept your insurance; as your provider may be updating their insurance or health plans. If your provider does not accept your insurance, you have the right to seek services from another provider in your area.

Patient advocacy center

The Patient Advocacy Center (PAC) is a service offered to members of our Value Based Payments (VBP) Health Plan. If you receive a balance bill from your provider for an amount above the deductible and co-insurance, please contact HST’s Patient Advocacy Center. A Patient Advocate will guide you through the process and handle all communication on your behalf.

Tel: (888) 837-2237
E-mail: pac@hstechnology.com
Fax: (949) 891-0420
HSTECHNOLOGY.COM

Oregon Associates

Coverage

Q: What is my coverage?
A: Adventist Health associates based in Oregon have the following coverage:

Tier One: Adventist Health for professional and facility.

  • 100% coverage: Professional and facility
  • $20 copay: Provider office visits

Tier Two: First Choice PPO for professional and facility.

  • 80% coverage: Professional and facility
  • $30 copay: Provider office visits

*If traveling outside of OR, utilize the First Health PPO network.

How to find a provider

Q: How do I find a provider?
A:
To find a provider visit AdventistHealth.org/EmployeeHealthPlan and select Find a Provider from the Member menu dropdown.

Tier One providers
To find a provider in Tier One providers must meet the following criteria:

  • Providers must be in the Adventist Health Medical Staff directory (use the search criteria above).

Tier Two providers

To find a provider in Tier Two providers must meet the following criteria:

*If traveling outside of Oregon, utilize the First Health PPO network.

Loma Linda Medical Center and Loma Linda Medical Center-Murrieta are considered Adventist Health facilities for medical benefits purposes.

Unavailable Service Request Forms

Q: What if my provider says I need a procedure that isn’t available from an in-network provider or at an in-network facility?
A: You must complete and submit an Unavailable Service Request Form (USRF). This form is needed for a medically necessary, covered service:

  • At any non-Adventist Health facility, and/or
  • With any non-Adventist Health or non-PPO provider

Q: Do I need pre-approval before I get care from out-of-network providers and facilities?
A: Yes, except for emergency and urgent care services.

Q: What happens if I don’t get pre-approval?
A: With the exceptions above, the service will not be covered.

Q: How do I know if a service or physician is available in-network?
A: Visit AdventistHealth.org/EmployeeHealthPlan and select Find a Provider from the Member menu dropdown to find a provider near you. If you believe medical services are not available from an in-network provider or facility, you or your provider should call Customer Service at (800) 441-2524. California members have the option of utilizing Tier Three Out-Of-Network coverage through HST’s Value-Based Payments.

Q: How is a determination made?
A: The health plan team verifies that the covered service is not available in-network.

Q: Why can’t I get treatment wherever I want?
A: You can. However, unless the covered service is with an Adventist Health or PPO provider and is provided in an Adventist Health facility, you will not be reimbursed (see emergency/urgent care exception).

Q: How do I submit an unavailable service request?
A: Follow these three steps:

  1. Log in to New Connect, the associate intranet portal. Select Employee Health Plan from the AH Services dropdown, scroll down and select Forms from the Resources section, then select the Prior Authorization-Unavailable Services Request Form. Follow all directions on the form.
  2. Once you’ve provided all the information needed to process the request, allow up to seven business days for review. You must get approval before the service is provided with the exception of urgent or emergency care.
  3. A team member from the Adventist Health Employee Health Plan will contact you by phone and/or send a letter to you and your provider once a determination is made.

All states excluding CA and OR

Coverage

Q: What is my coverage?
A:
First Health is our nationwide coverage for any associate residing outside of CA or OR.

Tier One: Adventist Health for professional and facility.

  • 100% coverage: Professional and facility
  • $20 copay: Provider office visits

Tier Two: First Health for professional and facility.

  • 80% coverage: Professional and facility
  • $30 copay: Provider office visits

How to find a provider

Q: How do I find a provider?
A:
To find a provider visit AdventistHealth.org/EmployeeHealthPlan and select Find a Provider from the Member menu dropdown.

Tier One providers
To find a provider in Tier One providers must meet the following criteria:

  • Providers must be in the Adventist Health Medical Staff directory (use the search criteria above).

Tier Two providers
To find a provider in Tier Two providers must meet the following criteria:

Loma Linda Medical Center and Loma Linda Medical Center-Murrieta are considered Adventist Health facilities for medical benefits purposes.

Unavailable Service Request Forms

Q: What if my provider says I need a procedure that isn’t available from an in-network provider or at an in-network facility?
A: You must complete and submit an Unavailable Service Request Form (USRF). This form is needed for a medically necessary, covered service:

  • At any non-Adventist Health facility, and/or
  • With any non-Adventist Health or non-PPO provider

Q: Do I need pre-approval before I get care from out-of-network providers and facilities?
A: Yes, except for emergency and urgent care services.

Q: What happens if I don’t get pre-approval?
A: With the exceptions above, the service will not be covered.

Q: How do I know if a service or physician is available in-network?
A: Visit AdventistHealth.org/EmployeeHealthPlan and select Find a Provider from the Member menu dropdown to find a provider near you. If you believe medical services are not available from an in-network provider or facility, you or your provider should call Customer Service at (800) 441-2524. California members have the option of utilizing Tier Three Out-Of-Network coverage through HST’s Value-Based Payments.

Q: How is a determination made?
A: The health plan team verifies that the covered service is not available in-network.

Q: Why can’t I get treatment wherever I want?
A: You can. However, unless the covered service is with an Adventist Health or PPO provider and is provided in an Adventist Health facility, you will not be reimbursed (see emergency/urgent care exception).

Q: How do I submit an unavailable service request?
A: Follow these three steps:

  1. Log in to New Connect, the associate intranet portal. Select Employee Health Plan from the AH Services dropdown, scroll down and select Forms from the Resources section, then select the Prior Authorization-Unavailable Services Request Form. Follow all directions on the form.
  2. Once you’ve provided all the information needed to process the request, allow up to seven business days for review. You must get approval before the service is provided with the exception of urgent or emergency care.
  3. A team member from the Adventist Health Employee Health Plan will contact you by phone and/or send a letter to you and your provider once a determination is made.