Frequently Asked Questions
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 in each plan.
If you need answers to other questions, or need to ask about a specific plan and benefits, please call a Member Advocate from 8 a.m. to 6 p.m. Monday through Friday at the phone number listed on your ID card.
What if I have questions?
Contact a Member Advocate at the number listed on your ID card.
Treatment Cost Calculator
Do you have questions about the Treatment Cost Calculator?
We developed this tool to help health plan members make the right decisions for their health and their budget. The answers to these frequently asked questions explain how treatment cost calculator estimates are produced, which costs are included in each estimate, and some hints that can help users take full advantage of the various resources available in the tool.
Member ID Cards
I have not received my member ID card but need to see my doctor. What should I do?
Contact a Member Advocate for assistance. If your enrollment via your plan sponsor has been processed, a Member Advocate 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 OhioHealthy. 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 the doctor’s office. You also have the option to print a temporary ID card online when you register. Click on Select member ID card under Benefits on the Members tab.
Why do I need to carry my member ID card?
Your member ID card identifies you as a covered member of OhioHealthy. Your card contains helpful information for your providers of service, including where to call for prior authorization. It also has helpful contact information including how to reach our Member Advocates, telemedicine provider, MDLIVE®, and our after- hours nurse advice line.
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, your information may have changed. Always present your new ID card to your doctor.
How do I request a member ID card?
You can contact a Member Advocate for assistance, or you can request a card by signing in to OhioHealthy online tools. Once ordered, the card should arrive in seven (7) to 10 business days.
Options for Treatment
Where should I go when I need care?
Knowing where to go when you are sick or injured can save you time and money. In an emergency situation, you should call 911 or go to the nearest emergency department. Nonemergency situations are best treated by your primary care doctor. If you don’t have a primary care doctor, you can use our online tools to find one or call our Member Advocates at the number on the back of your ID card.
For Nonemergency Illness or Injury:
Step 1: Call Your Doctor’s Office
If your doctor has an available appointment, follow the instructions provided by the office staff.
Step 2: Call a Member Advocate
If your doctor is not available, call the Member Advocate number on the back of your ID card. Our advocates will guide you to the most appropriate options for care.
If it is after regular business hours, call our Nurse Advice Line at 1 (844) 834.4375. This free call is your link to a licensed nurse who can assist you in determining your immediate next steps for care. Options include:
- MDLIVE®, an affordable option for talking with a doctor any time, using your computer, smartphone or tablet. You can also talk to a doctor by phone right away at 1 (888) 818.8502 . Please see the back of your card for copay information.
- Express Appointment Center. If your primary care doctor is not available, or you do not have a primary care doctor and need to be seen immediately, our Express Appointment Center can help. Call our Member Advocates for assistance with setting up an appointment.
- Urgent Care Centers offer same-day service for a variety of medical issues that need to be treated quickly but are not considered emergencies.
Whichever option you choose, please ask for information to be shared with your primary care doctor.
What happens when I call the After Hours Nurse Advice Line?
Nurse Advice Line nurses have training in emergency medicine, acute care, OB-GYN and pediatric care. 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.
The staff is 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.
Depending on the situation, you may be advised about appropriate home treatments or advised that a visit to your doctor will take care of it. If necessary, the nurse may direct you to a plan urgent care center or emergency department.
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 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 or severe chest pain
- Loss of pulse or breathing
- Loss of consciousness
What should I do if I have an emergency?
In any life-threatening emergency situation, always call 911 or go to the closest emergency department.
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.
What conditions generally do not require emergency department treatment?
The following conditions do not ordinarily require emergency department treatment, and may be more appropriately treated in your doctor’s office, or at an urgent care center covered by your plan:
- Sprains or strains
- Chronic conditions such as arthritis, bursitis, or backaches
- Minor injuries and puncture wounds of skin
- Colds, Flu, Fever, Sore Throat
- Ear Infection
- Sinus Infection
- Urinary Tract Infections
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 or coinsurance.
Do I need to contact OhioHealthy or my primary care physician before going to the emergency department or urgent care center?
No. In case of an emergency, you should always call 911 or go to your nearest emergency department. In non-emergent situations, if you are unsure where to go for the treatment of your condition, you can call your primary care doctor's office or a Member Advocate. If it is after business hours, you can call the 24/7 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 OhioHealthy 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 a Member Advocate at the number on your ID card. If it is after business hours, contact the 24/7 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.
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.
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 the Medical or Behavioral Health Preauthorization number on the back of your card.
What happens once I am admitted to the hospital?
As part of your OhioHealthy coverage, a member of our clinical team 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.
Behavioral Health Services
How do I access behavioral health services?
You may contact either a Member Advocate or your primary care physician for guidance prior to seeing a behavioral health provider.
Do I need a referral for behavioral health inpatient services?
No. If you need to be hospitalized, your behavioral health provider (not your primary care physician) will arrange for your admission to the appropriate in-network facility.
How do I handle a behavioral health emergency?
In an emergency, always call 911 or go to the nearest emergency department. For nonemergency behavioral health information, contact a Member Advocate or the 24/7 Nurse Advice Line. The numbers are 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.
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 doctor for specialist care. If you and your doctor decide you need to see a specialist, your doctor will coordinate your care and you can make your own appointment.
Before you see a specialist, you should confirm that the specialist is in the OhioHealthy Network. Use the Find Doctors and Locations search tool 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 locations.
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 your plan’s allowable charges.
To find an in-network doctor, use the Find Doctors and Locations search tool, 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 preauthorization by OhioHealthy. You can call a Member Advocate or your specialist can call the preauthorization number on the back of your ID card to confirm.
Do I need a referral for my annual gynecologic exam?
No. Your plan does not require referrals. Members may schedule an appointment for a routine annual exam with any OB-GYN in OhioHealthy’s Network.
Can an obstetrician (OB) serve as my primary care doctor while I am pregnant?
Yes, during your pregnancy, your OB can serve as your primary care doctor. As a plan member, you are automatically eligible for the OhioHealthy 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 OhioHealthy doctors and locations.
You have the option of using OhioHealthy providers or non-OhioHealthy providers. Because OhioHealthy does not have cost-saving contracts in place with providers not in our network, you will usually pay more for their services. You may also be balance billed for any charges in excess of your plan’s allowable charges.
To find an in-network doctor, use the Find Doctors and Locations search tool (https://ohiohealthyplans.prismisp.com/), 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 underscores (_).
- 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, select 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 using the OhioHealthy website?
Contact a Member Advocate at the number on the back of your ID card.