Frequently Asked Questions
Important note: Be advised that the following answers to frequently asked questions are general guidelines for health plans offered by OhioHealthy. While most of the answers apply to all plans offered by OhioHealthy, there may be some slight differences. Please refer to your member materials or call a Member Advocate for information on your specific health plan.
If you need answers to other questions or need to ask about a specific plan and benefits please call the Member Advocate number from 8 a.m. to 6 p.m. Monday through Friday at the phone number listed on your ID card.
What plans do you offer?
OhioHealthy offers many products for large and small group employers. It is best to check with your employer to see if a health plan by OhioHealthy is an option for you.
When and where do I call if I have questions?
Refer to this section of the Web site for answers to commonly asked questions. If you still have questions, contact the Member Advocate number.
Treatment Cost Calculator
Do you have questions about the Treatment Cost Calculator?
Thank you for exploring the OhioHealthy Treatment Cost Calculator. OhioHealthy developed this tool to help our health plan members make informed decisions that are best for their health and their budget.
These frequently asked questions (FAQs) provide an overview of how Treatment Cost Calculator estimates are produced, what costs are included in each estimate, and some helpful hints to help users take full advantage of the various resources available in the tool. These FAQs will evolve based on the user experience, so check back for updates.
Member ID Cards
I have not received my Member ID card but need to see my doctor. What should I do?
Contact your Member Advocate. If your application has been processed they will be able to give you your unique Member ID number. This number allows a doctor to verify your eligibility and bill your services to the health plan. If your doctor requires you to present a card at the time of service, a Member Advocate will fax a sample of your card to his/her office.
Why do I need to carry my Member ID card?
Your Member ID card identifies you as a covered member of OhioHealthy. In addition, it provides information such as copay or coinsurance amounts, applicable deductibles, your Member ID number, and important phone numbers and addresses.
I received a new Member ID card in the mail but I already have one. Should I throw the new one away?
No. Unless you ordered a new card online or through a Member Advocate the only reason you will receive a new card is if important information on it has changed. Always show your ID card to your doctor when you receive a new one.
How do I request a Member ID Card?
Sign in and view OhioHealthy tools online or call a Member Advocate. Once ordered the card should arrive in seven (7) to ten (10) business days.
After Hours Nurse Advice Line
Do You Need After Hours Nurse Advice?
Call the number on the back of your Member ID card.
Remember, in an emergency always call 911 or go to the nearest emergency department.
What should I do if I get sick or hurt after business hours or during the weekend?
If you have an illness, injury, or condition that occurs during an evening or weekend, you should call your PCP or Plan doctor’s office or the After Hours Nurse Advice Line number located on your Member ID card.
What happens when I call the After Hours Nurse Advice Line?
A registered nurse will ask you to describe your medical situation in as much detail as possible. Be sure to mention any other medical conditions that you have, such as diabetes or hypertension.
Depending on the situation, you may be advised about appropriate home treatments or advised that a visit to your Plan doctor will take care of it. If necessary, the nurse may direct you to a Plan urgent care center or emergency department.
After Hours Nurse Advice Line nurses have training in emergency medicine, acute care, OB/GYN, and pediatric care. The staff are well-prepared to answer medical or behavioral health questions for members and their dependents. However, since they are unable to access medical records, they cannot diagnose or medically treat conditions, order labs, write prescriptions, order home health services, or initiate hospital admissions or discharges.
What should I do if I have an emergency?
In any life-threatening emergency situation, always go to the closest emergency department or call 911.
If you received emergency care and are admitted, you or a family member should contact OhioHealthy within 48 hours (two business days) or as soon as medically possible. This enables OhioHealthy to arrange for appropriate follow-up care, if necessary. Also, note that in each of these situations care may be reviewed retrospectively to make sure it met the criteria for coverage of emergency/urgent care treatment.
How can I tell if it is an emergency?
An emergency is the sudden onset of a medical condition with such severe symptoms or pain that an average person with an average knowledge of health and medicine (prudent layperson) would seek medical care immediately because there may be serious risk to your physical or mental health or that of your unborn child.
Some examples of situations that would require the use of an emergency department include but are not limited to:
- heart attack/severe chest pain
- loss of pulse or breathing
- loss of consciousness
What conditions generally do not require emergency department treatment?
The following conditions do not ordinarily require emergency department treatment, and maybe more appropriately treated in your doctor’s office, or at a Plan urgent care center:
- sprains or strains
- chronic conditions such as arthritis, bursitis, or backaches
- minor injuries and puncture wounds of skin
What is the difference between an emergency department and an urgent care center?
An emergency department is designed, staffed, and equipped to treat life-threatening conditions. An urgent care center is a more appropriate place to seek treatment for sudden acute illness and minor injuries when your doctor’s office is closed or not available. Copayments and coinsurance amounts for emergency department visits are generally higher than copayments for urgent care visits. If you are transferred to an emergency department from an urgent care center, you will be charged an emergency department copayment/coinsurance.
Do I need to contact OhioHealthy or my primary care physician before going to the emergency department/urgent care center?
No. However if you are unsure whether to visit an emergency department or urgent care center, you can call your primary care doctor's office or the After Hours Nurse Advice Line at the number on your ID card.
What if I become ill when I am outside of OhioHealthy’s service area?
Your Plan includes coverage for emergency services when you are outside the service area. If you have an unexpected illness or injury when outside of the service area you should call the After Hours Nurse Advice Line at the number on your ID card. In any life-threatening emergency situation always go to the closest emergency department or call 911.
Remember, OhioHealthy may review all emergency department care retrospectively – after the fact—to determine if a medical emergency did exist. If an emergency did not exist you may be responsible for payment for all services.
What if I need to be hospitalized?
If you received emergency care and are admitted, you or a family member should contact OhioHealthy within 48 hours (two business days) or as soon as medically possible. This enables OhioHealthy to immediately begin reviewing your care and to arrange for appropriate follow-up care. Remember all emergency care may be reviewed retrospectively to make sure it met the criteria for coverage of emergency/urgent care treatment.
If you are admitted to a hospital outside of OhioHealthy’s service area, call a Member Advocate or the After Hours Nurse Advice Line at the number listed on your member ID card. Be prepared to give the following information:
- Member name
- Reason for treatment
- Hospital name
- City and state where treatment is occurring
- Name of treating doctor
The doctor or hospital may also call Clinical Care Services.
What happens once I am admitted to the hospital?
As part of your OhioHealthy coverage, a case manager will follow your case from beginning to end. He or she will review your chart daily, check your progress, and arrange for your continuing care needs after you leave the hospital.
Mental Health Services
What about mental health services?
You may contact either a member advocate or your primary care physician for guidance prior to seeing a mental health provider.
Is a referral for mental health inpatient services required?
No. If you need to be hospitalized, your mental health provider (not your primary care physician) will arrange for your admission to the appropriate in-network facility
Is there a way to handle emergencies for mental health?
Yes. Remember, in an emergency always call 911 or go to the nearest emergency department. For non-emergency behavioral health information after hours please call After Hours Nurse Advice Line at the number listed on the back of your member ID card.
Authorization for Use or Disclosure of Medical Information
How does OhioHealthy protect my personal information?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health plans protect the confidentiality of your private health information. OhioHealthy will not use or further disclose HIPAA protected health information (PHI) except as necessary for treatment, payment, and health plan operations, as permitted or required by law, or as authorized by you.
A complete description of your rights under HIPAA can be found in the OhioHealthy Integrated Notice of Privacy Practices. A copy of the notice will be included in your Evidence of Coverage (EOC) or Certificate of Insurance (COI) when you enroll. You can view a copy of our privacy notice online.
The state of Ohio also has laws in place to protect the privacy of our members’ insurance information. We will not release data about you unless you have authorized it, or as permitted or required by law. OhioHealthy requires an Authorization of Designated Agent form whenever anyone other than the OhioHealthy member needs to obtain and/or change health information. You can download a copy of the form under Forms and Documents, or by calling a Member Advocate at the number on your ID card.
Under HIPAA and Ohio law you have certain rights to see and copy health information about you. Under HIPAA you have the right to request an accounting of certain disclosures of the information and under certain circumstances, amend the information. You have the right to file a complaint with OhioHealthy or with the Secretary of the U.S. Department of Health and Human Services if you believe your rights under HIPAA have been violated.
Primary Care Physicians
What is a primary care physician (PCP), and why do I need one?
Your Plan primary care physician (PCP) is your point of contact to coordinate your healthcare needs. They can provide both the first contact for an undiagnosed health concern as well as continuing care of varied medical conditions. Depending on your PCP for routine medical care and guidance when seeking care within the OhioHealthy network can increase your satisfaction with the Plan and with your care. You will be asked to select an in-network or Plan PCP for yourself and each of your eligible dependents when you enroll.
How do I choose a PCP?
When you enroll in an OhioHealthy Plan, you will be asked to choose a PCP for yourself and each of your dependents. New members can often continue relationships with their present doctor or select a doctor with an office more convenient to their home or work addresses. You have the right to choose any PCP who participates in our network and who is available to accept you and/or your dependents. For children, you may choose a participating pediatrician as their PCP.
You can review a list of participating providers for your Plan online at OhioHealthyPlans.com. You can choose or change your PCP online by signing in, selecting Change Primary Care Physician from your OhioHealthy online tools, and following the onscreen instructions. In most cases, your PCP selection will be effective the next business day.
You can review a list of participating providers for your Plan online at OhioHealthyPlans.com. You can choose or change your PCP online by signing in, selecting Change Primary Care Physician from the OhioHealthyPlans.com menu, and following the onscreen instructions. In most cases, your PCP selection will be effective the next business day.
If you have not seen your designated PCP within the last 24 months, please contact your PCP’s office or a Member Advocate to ensure that the office still lists you as a patient. Having your correct PCP on file ensures that any correspondence or other outreach to your PCP is accurate.
What about my spouse and children? Do we all have the same PCP?
You have the right to choose any PCP who participates in our network and who is available to accept you and/or your family members. You may select the same PCP for everyone, or each member can select their own PCP.
Generally, adults choose a family practice or internal medicine doctor for their PCP. For children, you may choose a participating pediatrician as their PCP.
What if my Plan doctor leaves the OhioHealthy network?
If your Plan doctor leaves the network, OhioHealthy will notify and assist you in finding a new doctor or facility. If you are in active treatment with a doctor who leaves the network you can request to continue receiving healthcare services from the doctor for at least 90 days. If you are beyond the first trimester of pregnancy you may be able to remain with that doctor through the provision of postpartum care directly related to the delivery. For a terminal illness, treatment may continue for the remainder of the member’s life for care directly related to the terminal illness.
Referrals are not required for any OhioHealthy plans.
What if I need to see a specialist?
You do not need a referral from your Primary Care Physician for specialist care. If you and your PCP decide you need to see a specialist, your PCP will coordinate your care and you can make your own appointment. Before you see a specialist, you should confirm that the specialist is in OhioHealthy's network. Visit Find a Doctor or contact a Member Advocate at the number on your ID card to make sure that your specialist is in the network.
What if my doctor directs my care to a non-network doctor?
It is your responsibility to ensure that you are using in-network doctors and facilities. If you have an OhioHealthy plan and your doctor directs you to a non-network doctor, you will be responsible for payment of these services. You have the option of using in-network doctors or out-of-network doctors. Claims from out-of-network doctors will be paid at a reduced benefit level and you will usually pay higher deductible, copay, and coinsurance amounts. You may also be balance-billed for any charges in excess of the Plan’s allowable charges. To find an in-network doctor, use the Find a Doctor or Find a Facility search feature or call a Member Advocate at the number on your Member ID card.
Is my specialist authorized to order diagnostic or X-ray tests for me?
Yes, but some tests may require pre-authorization by the Plan.
Do I need a referral for my annual GYN exam?
No. Your plan does not require referrals. Female members may schedule an appointment for a routine annual exam with any OB/GYN in OhioHealthy’s network.
Can an OB serve as Primary Care Physician while I am pregnant?
Yes, during your pregnancy, your OB can serve as your PCP. As a Plan member, you are automatically eligible for OhioHealthy’s Partners in Pregnancy program. This program is designed to provide education and support to pregnant women. To learn more and register, call (614) 788.WELL (9355) or email PartnersinPregnancy@OhioHealthGroup.com.
Who is responsible for making sure the doctors I see and the services I receive are covered under my health plan?
It is your responsibility to ensure that you are using in-network or Plan doctors and facilities.
If you have a PPO plan, you have the option of using Plan providers or non-Plan providers. Claims from non-Plan providers will be paid at a reduced benefit level and you will usually pay higher deductible, copayment, and coinsurance amounts. You may also be balance billed for any charges in excess of the Plan’s allowable charges. To find a Plan provider, use the Find a Doctor, or Find a Facility search feature, or call a Member Advocate at the number on your Member ID card.
I’m having trouble signing in. What can I do?
Ensure you are following username and password requirements:
- Usernames must begin with a letter and include only letters (a-z or A-Z), numbers (0-9) and underscore (_).
- Usernames cannot include spaces or special characters and are not case sensitive.
- Usernames can be a maximum of 20 characters long.
- Passwords must be at least eight characters, include only letters (a-z or A-Z), numbers (0-9) and underscore (_).
- Passwords cannot include spaces or special characters.
- Passwords are case sensitive.
How do I register?
If you are age 14 or older and a covered member of the health plan, simply go to the registration page. You will need to have your Member ID card available when registering.
Not yet registered? Register now
I have forgotten my Username and Password, what do I need to do?
If you have forgotten your password, visit Change Password. The secret answer you supplied during the registration process will allow you to reset your password. Keep in mind that the answer to your secret question is case sensitive. If you can’t remember the answer to your secret question, you will need to contact a Member Advocate to have your password reset.
If you have forgotten your username you can complete the first step of the registration process again to recover your username. If you have previously set up a username, your username will appear at the top of the registration page after you have submitted the registration form. You may also contact a Member Advocate to find out your username.
Who should I contact for help?
Contact a Member Advocate.