How to Seek Care, Out of Network

Using out-of-network providers

If you seek care outside the network, the plan works a little differently. Here’s what you need to know:

	Show your LM HealthWorks Plan medical ID card.
	Depending on the provider, you may need to pay in full at the time of your visit, then submit a claim to Aetna, the LM HealthWorks Plan administrator, for reimbursement. Remember, when you use out-of-network providers, you are responsible for filing claims.
	You can call the LM HealthWorks Plan toll-free number at 1-877-458-4975 to request a claim form. Or, you can download a claim form at the Aetna member website. Follow the instructions on the form and remember to include the provider’s original bill for services.
	Once you have filed a claim, you will receive a Monthly Claims Summary by mail or online that shows the total charge for care and the amount the plan will pay. It also shows how much of the out-of-network deductible you’ve met including any amount from your Healthfund applied, and how much remains to be met.
	If there’s a balance in your HealthFund, the appropriate amount is withdrawn automatically to pay your share of the expenses. This amount is also applied toward your calendar year out-of-network deductible. (Note that the plan’s in-network and out-of-network deductibles are separate. Out-of-network expenses do not apply toward the in-network deductible and vice versa.)
	If your HealthFund balance is depleted before the deductible is met, you pay for your care out of your own pocket until the deductible is met. This is also true if there’s a zero balance in your HealthFund at the time you incur the expense.
	After the deductible is met, you and the plan share in the cost of your care. You pay a percentage of your expense (called coinsurance).  For covered preventive care services, the plan typically pays 100% of the recognized charge with no deductible. The Benefits Summary chart shows how you and the plan share expenses.
	Once the claim is processed, you are reimbursed for the plan’s share of the covered expense. Payments to the provider will be your responsibility.

Keep in mind that out-of-network expenses are paid according to what the plan considers the recognized charge, that is, the charge most often made for a service or supply in a geographic area. If your health care provider charges more than the recognized charge, you pay the difference.

If you are receiving ongoing care from an out-of-network doctor, you may want to consider nominating him or her for membership in the network. Learn more »

Once you become a member of the LM HealthWorks Plan and register for the Aetna member website, you can check the status of a claim, your HealthFund balance and progress toward your deductible at the Aetna member website.

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