Sagamore Plus or Sagamore Select
Preferred Provider Organization (PPO)
Benefit plans vary widely. The information presented in this section is general
in nature; is intended to be informational only and, as such, is superceded by
your specific benefit plan. Please refer to your Benefit Plan Description,
including all attached Certificate Riders, for complete details of coverage
including benefit exclusions and limitations.
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We have tried to answer each question clearly. If you have a question not
covered here or an answer we give to one of these questions is not clear,
please use the Ask Us link and
we will respond as soon as possible. Your question may also be added to this
list to help others.
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we can respond to you in the appropriate manner. Thank you!
Don't forget to include:
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Your Name.
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The e-Mail address to which you would like the response to go if different from
the originating e-Mail address. We will automatically respond to the originating
e-Mail address unless you include another "preferred" address.
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Your Phone Number if you would like someone to call you.
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Your mailing address if you are requesting a Provider Directory to be mailed to
you.
A. Sagamore is a managed
health care company based in Indiana with over 200 hospitals and over 42,000 physicians
and other medical care providers. We're committed to Indiana, so we work closely
with local providers to provide our customers with a comprehensive and competitive network.
Our hospitals are all JCAHO accredited and/or Medicare approved. All of our physicians are
credentialed according to nationally recognized standards.
Contrary to popular belief, in this role, Sagamore is
not the insurance company. Sagamore's network is "accessed" through
contracts with over 120 health insurance companies, third party administrators,
self-insured firms and Health & Welfare trusts.
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A. When you use the services of a
Sagamore network medical provider, the claim (bill) is sent to Sagamore to be
re-priced based upon the fee that was negotiated with that provider. The
re-priced claim (bill) is then forwarded to the payor (the insurance company or
third party administrator) for processing based on the specific benefit
provisions of the plan. Sagamore providers are obligated to write off the
difference between their billed charge and the re-priced amount for covered
services. The amount to be "written off" or "discounted" by the provider is
normally spelled out in the Explanation of Benefit (E.O.B.) provided to both
the provider and the member.
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A. A PPO is a managed care
arrangement created to offer quality, cost effective healthcare through a
network of respected, well-established physicians, hospitals and other medical
care providers.
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A. The
Sagamore PPO network provides the following advantages to a member and/or
dependents.
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Save money when using Sagamore physicians because of receiving higher benefit
levels and paying a smaller share of costs.
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May still use any physician, even those outside the Sagamore Network if willing
to share a larger portion of the cost for covered services and file claim
forms.
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There are no claim forms to file when using a Sagamore hospital or physician.
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Unlike some HMO plans, members are not restricted to only Sagamore physicians.
They may go to any physician or hospital of choice and still receive reasonable
benefit coverage.
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A. You will receive a copy of a
Sagamore Provider Directory. This directory is reprinted and updated once
annually and physicians are continually added (and some removed) between
reprints. To minimize potential problems and decrease costs for you, it is
always a good idea to check the physician's network status before making an
appointment. This can be done by calling Sagamore at (800) 364-3469. You
are also able to get this information from the Sagamore web site by clicking on
the Customized Provider Directory link.
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A. NO. You receive better benefit
coverage by using the Sagamore providers. However, if you choose a
non-participating provider, your benefits will be lower, so you will pay a
larger portion of the cost. Unlike some health plans, you have the
freedom to choose the hospital and physician that best meets your
health care needs.
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A. A PPO plan does not normally
require preselection of a PCP. In most plans, you can choose to use any
physician at any time. Benefit levels, however, are subject to whether the
provider is IN or OUT of the network.
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A. The decision is yours. Sagamore
physicians should refer you to other Sagamore providers. If you choose to use
an out of network physician or provider, however, bear in mind you will be
subject to OUT of network benefits and will likely have to pay more out of your
pocket.
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A. Costs are lower for covered
services in the Network for the following reasons:
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Participating providers agree to negotiated fees or discounts.
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You are not balance billed for the difference between the negotiated fee and
the actual charge.
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Your share of the cost for medical service and co-insurance is lower for
services rendered in the network.
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