Download Submit claims to: Sagamore Health Network SAG1428 PO Box 6051

009DXN - PLAN YEAR BENEFITS: 03/01/2012 - 02/28/2013
COPAYS
Primary Dr.
Specialist Dr.
Emergency Room
SERVICES WITH LIMITATIONS
Chiropractic
Home health*
Physical/Occupational/Speech Therapy
in any combination*
$35
$45
$200
IN NETWORK
$3000
20/80
DEDUCTIBLE
CO-INSURANCE
AREA
PPO NETWORK
Indiana/Ohio
If you have an emergency or illness
while traveling outside the
Sagamore service area, or if you are
a dependent residing outside that
area, you can access PPO providers
through PHCS Healthy Directions.
All other Providers
VISITS/YR
10
60
50
OUT OF NETWORK
$6000
40/60
Submit claims to:
Sagamore Health Network
SAG1428
PO Box 6051
Indianapolis IN 46206-6051
Ph: 800-320-0015
PHCS
EDI# 37086
Pekin Life Ins Co
PO Box 823
Buckeystown MD 21717
Ph: 888-955-7427
Group Plan Solutions
2505 Court Street
Pekin IL 61558
Precertification is required for inpatient hospital stay, outpatient elective
surgery, or a hi-tech diagnostic procedure, such as hitech MRI.
PRECERTIFICATION
(888) 641-5304
*PRIOR
AUTHORIZATION
(888)301-0747
Emergency care rendered by a non-preferred provider, for inpatient services,
will be calculated using in-network benefits; however, once a referral can be
made to safely transfer the patient to the care of a preferred provider,
continued services by the non-preferred provider will be calculated using the
out-of-network benefits.
*Prior Authorization is required for skilled nursing, home health, injectable
medications, durable medical equipment, orthotics and prosthetics.
Ext. 2576 for orthotics, prosthetics or DME.
Ext. 2782 for skilled nursing, home health, or injectable medications.
Please be advised that we do not guarantee benefits prior to a claim being submitted and
approved. All plan provisions, exclusions, and limitations will apply.
Eligibility and claim status is available online. See provider resources at
www.groupplansolutions.com.
For claim questions, call 888-301-0747.