Frequently Asked Questions

Contact a Member Advocate at the number listed on your ID card.

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 access to an electronic ID card by signing into your OhioHealthy account or downloading the OhioHealthy App.

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 and our after-hours nurse advice line.

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.

You can contact a Member Advocate for assistance, or you can request a card by signing into your OhioHealthy account. Once ordered, the card should arrive in 7-10 business days. 

Pursuant to the Billing section of your Participating Provider Agreement with OhioHealthy, Providers shall submit claims on the appropriate claim form as determined by OhioHealthy for all Covered Services within three hundred sixty-five (365) days of the date those services are rendered.

All claims for services rendered for dates of service in calendar year 2023 not submitted within 365 days, and by 12/31/24, will be denied for payment and Provider shall hold OhioHealthy, the applicable Beneficiary, and the Payor financially harmless for the payment of such claims.  If you are a Provider with additional questions please email us at providerrelations@ohiohealthyplans.com.  If you are a member with additional questions please email us at Inquiry@ohiohealthyplans.com.

If you would like to submit an appeal, you can initiate the appeals process by calling us at (855) 571-1378. You can also fax us at (717) 295-1208.

If you have already initiated the process by calling, you can use the address below for the second level of appeal.

OhioHealthy Appeals Department
P.O. Box 4278
Clinton, IA 5273-4278

You have the best experience when you choose the right care from the start. When you need care, you may have more options than you realize—ones that could save you time and money. 

If you are experiencing a life-threatening emergency, call 911 or go to the nearest Emergency Department. 

For non-emergency care, contact your primary care physician to schedule an appointment. Depending on your physician, virtual care from your mobile device or computer may be an option. If you don’t have a primary care physician, use the OhioHealthy Provider Search Tool. 

If your primary care physician is not available: 

Option 1 | CONTACT A MEMBER ADVOCATE 

Contact a Member Advocate Monday through Friday 8:00 AM – 5:00 PM by calling the number on the back of your member ID card. 

Option 2 | CALL THE FREE NURSE SUPPORT LINE 

Contact a licensed nurse 24/7 for support or questions by calling (866) 366-6877. 

Option 3 | SCHEDULE A VIRTUAL CARE VISIT 

Schedule a virtual visit with Teladoc through the convenience of your mobile device or computer. Teladoc is a national network of on-demand providers offering 24/7 access to board-certified physicians. Download the Teladoc Mobile App or visit Teladoc to get started. 

Have questions about where to go for care? Contact a Member Advocate by calling the number on the back of your member ID card. 

OhioHealthy understands the importance of maintaining your health coverage without interruption in your medical treatments. If you have a future procedure scheduled, or if you are currently receiving treatment for an on-going condition by a provider not in the network you may need added support in your switch to OhioHealthy. If this applies to you, please submit a Transition of Care Assessment within 30 days of the OhioHealthy plan coverage start date. Transition of care to an in-network provider should be accomplished within 90 days of starting coverage.

Once your Transition of Care Assessment has been reviewed, a member of the care management team will contact you to assist with finding in-network providers and create a plan to ensure a smooth transition. 

The 24/7 MyNurse Support Line nurses have training in emergency medicine, acute care, OB-GYN and pediatric care. A nurse will ask you to describe your medical situation in as much detail as possible. Be sure to mention any other medical contions 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 treat medical 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 a visit to your doctor may be advised. If necessary, the nurse may direct you to a plan urgent care center or Emergency Department.

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 Eemergency Ddepartment include but are not limited to: 

• Heart attack or severe chest pain 
• Loss of pulse or breathing 
• Stroke 
• Poisoning 
• Loss of consciousness 
• Seizures 

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. 

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 

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.

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 the 24/7 MyNurse Support Line.  

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 MyNurse Support Line at the number on your ID card. 

If you are in a life-threatening emergency, call 911 or go to the closest Emergency Department. 

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. 

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. 

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 medical record, check your progress and arrange for your continuing care needs after you leave the hospital.

You may contact either a Member Advocate or your primary care physician for guidance prior to seeing a behavioral health provider.

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.

In an emergency, always call 911 or go to the nearest Emergency Department. For nonemergency behavioral health information, contact your behavioral health provider, a Member Advocate or the 24/7 MyNurse Support Line. The Member Advocate and 24/7 MyNurse Support Line numbers are listed on the back of your member ID card.

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. 

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. 

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 maximum 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. 

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.

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.

Yes, during your pregnancy, your OB can serve as your primary care doctor. As a plan member, you are automatically eligible for the OhioHealthy Pregnancy Program. This program is designed to provide education and support to pregnant women. To learn more and register, call (614) 485-7941 or email caremanagement@ohiohealthyplans.com.

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. 

Your OhioHealthy account is mobile friendly and has all of the convenient features you need to stay connected including: 

• Find/print ID cards 
• Find/locate providers 
• Estimate costs through the treatment cost calculator 
• Contact a member advocate 
• Check the status of an open and/or paid claim 
• Update contact information 
• Schedule virtual care visits for medical and behavioral healthcare 

Not yet registered? Register now 

Yes. Download the “OhioHealthy app” from the Apple Store or Google Play.

On the login screen, select "Forgot your username or password?" and follow the reset instructions. You may also contact a Member Advocate for assistance.

As a member of OhioHealthy, you have a wide range of valuable covered health benefits that you are entitled to receive. To enjoy the most beneficial, efficient, and affordable healthcare experience it is important that you become familiar with how your health plan works. Follow the established procedures and use the approved network of doctors, hospitals, mental health providers and other specialists who participate with OhioHealthy. Your OhioHealthy Member Advocate can help you at any time. Here are a few things you should know: 

OhioHealthy plan members have the right to: 

1. Timely and Quality of Care: 

• Access to Protected Health Information (PHI), medical records, physicians and other healthcare professionals and referrals to specialists when medically necessary. 
• Continuity of care, and to know in advance the time and location of an appointment, as well as the physicians and other healthcare professionals providing care. 
• Receive the medical care that is necessary for the proper diagnosis and treatment of any covered illness or injury. 
• Participate with physicians and healthcare professionals in: 
  • Discussing their diagnosis, the prognosis of the condition and instructions required for follow-up care. 
  • Understanding the health problems and assisting to develop mutually agreed-upon goals for treatment. 
  • Decision-making regarding their healthcare and treatment planning. 
  • A candid discussion of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage. 
• The right to affirm that all practitioners, providers and employees who make utilization management (UM) decisions: 
  • Base decisions on appropriateness of care, services and existence of coverage. 
  • Are not rewarded for issuing medical denials of coverage. 
  • Do not encourage decisions that result in underutilization through financial incentives. 

2. Treatment with Dignity and Respect — members will: 

• Be treated with respect, dignity, compassion and the right to privacy. 
• Exercise these rights regardless of race, physical or mental ability, ethnicity, gender, sexual orientation, creed, age, religion or their or their nation of origin, cultural or educational background, economic or health status, English proficiency, reading skills or source of payment for their care. Expect this right by both in-network and contracted physicians. 
• Expect protection of all oral, written, and electronic information across the plan, and information to plan sponsors and employers. 
• Extend their rights to any person who may have the legal responsibility to make decisions on the member’s behalf regarding medical care. 
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. 
• Be able to refuse treatment or to sign a consent form if the member feels they do not clearly understand its purpose or cross-out any part of the form they do not want applied to their care or change their mind about any treatment for which they have previously given consent and be informed of the medical consequences of this action. 

3. Receive Health Plan Information — members will: 

• Receive information about their health plan, its services, its physicians, other health care professionals, facilities, clinical guidelines and member rights and responsibilities statements, and collection, use, and disclosure of PHI. 
• Know by name, title, and organization the physicians, nurses or other healthcare professionals providing care. 
• Receive information about medications (what they are, how to take them and possible side effects) and pharmacy benefit information (effective date of formulary change, new drugs available or recalled medications). 
• Receive clear information regarding benefits and exclusions of their policy, how medical treatment decisions are made and authorized by the health plan or contracted medical groups, payment structure and the right to approve the release of information. 
• Be advised if a practitioner proposes to engage in experimentation affecting care or treatment. The member may have the right to refuse to participate in such research. 
• Be informed of policies regarding Advance Directives (living wills) as required by state and federal laws. 

4. Resolve Problems in a Timely Manner by: 

• Presenting questions, concerns or complaints to a Member Advocate without discrimination, and expect problems to be fairly examined and appropriately addressed. 
• Voicing concerns or complaints to OhioHealthy about their health plan if the care provided was inadequate or if the member feels their rights have been compromised. This includes the right to appeal an action or denial and the process involved. 
• Making recommendations regarding the health plan member’s rights and responsibilities policies.  

In addition to your rights as OhioHealthy plan members (subscribers and their enrolled dependents), you also are an important part of the team and have certain responsibilities. 

Member responsibilities include the requirement to: 

• Identify themselves, and their family members as an OhioHealthy enrollee and present their identification cards when requesting healthcare services. 
• Be on time for appointments and contact the physician or other healthcare personnel at once if there is a need to cancel or if they are going to be late for an appointment. If the physician, other healthcare personnel or facility has a policy assessing charges regarding late cancellations or “no-shows,” the member will be responsible for such charges. 
• Provide information about their health to physicians and other healthcare professionals so they may provide appropriate medical care. 
• Actively participate and understand improving their health conditions by following the plans and instructions for care and treatment goals that they agreed upon with the physician or healthcare professional. 
• Act in a manner that supports the care provided to other patients and the general functioning of the office or facility. 
• Review the Summary of Benefits and Coverage (SBC) and plan documentation: 
  • To make sure the services are covered under the plan. 
  • To approve release of information and have services properly authorized before receiving medical attention. 
  • To follow proper procedures for illness before and after business hours. 
  • For materials concerning health benefits (for example, utilization management (UM) issues) and educate other covered family members. 
• Accept financial responsibility for any copayment or coinsurance associated with services received while under the care of a physician or other healthcare professional, or while a patient at a facility. 

Contact OhioHealthy if they have concerns, or if they feel their rights have been compromised. 

Thanks to the passing of the No Surprises Act, those enrolled in health insurance plans, including OhioHealthy, can find assurance knowing they will never receive unexpected invoices for out-of-network healthcare services. The No Surprises Act went into effect on January 1, 2022, and is designed to protect plan members who receive out-of-network emergency care, as well as those who obtain care at an in-network hospital but are treated by an out-of-network healthcare provider.

By law, those who receive emergency care from an out-of-network facility can no longer be charged a premium by those providers. The patient can only be charged at their plan’s in-network copay and coinsurance rates, even after they are in stable condition (unless the patient consents to waive that protection in writing). No additional balance or surprise invoices can be issued by the out-of-network emergency or urgent-care facility.

There are also occasions when a plan member might receive care from an out-of-network care provider despite being at an in-network facility. In these instances, the provider can only invoice according to the plan’s established in-network rates. The No Surprises Act states that its protections apply to all hospital services, including but not limited to the following:

• Anesthesia
• Assistant surgeons, hospitalists, and intensivists
• Emergency medicine
• Laboratory, pathology, and radiology
• Neonatology

The No Surprises Act does not currently apply to ground ambulance trips, although it does limit surprise billing for air medical transport.

Click to learn more about the No Surprises Act.

Health plan price transparency helps consumers know the cost of a covered item or service before receiving care. Beginning July 1, 2022, most group health plans and issuers of group or individual health insurance began posting pricing information for covered items and services. This pricing information can be used by third parties, such as researchers and app developers to help consumers better understand the costs associated with their health care. More requirements will go into effect starting on January 1, 2023, and January 1, 2024, which will provide additional access to pricing information and enhance consumers' ability to shop for the health care that best meet their needs.

The link below leads to machine-readable files (MRF) that contain negotiated service rates and out-of-network allowed amounts between health plans and healthcare providers. These files are being provided as required by the Federal Transparency in Coverage Rule. Please note that these files are often very large and are formatted in JavaScript Object Notation (JSON) configuration to enable effective data analysis for researchers, regulators, and application developers. Members needing specific information about cost of services are encouraged to contact their OhioHealthy plan.

These files are accessible here (https://mrf.healthcarebluebook.com/luminarehealth).