As an insurance shopper and consumer, you probably have a lot of questions. In this section, we present the most frequently asked questions (and the answers) on a variety of health insurance topics.

Oxford Freedom Plan Answers

The Oxford Freedom Plan, provides all Members with the choice, flexibility, security and information they look for from their medical coverage. The Freedom Plan covers healthcare in two ways.

The In-Network side of the Freedom Plan provides you access to Oxford's Network of highly-qualified physicians. When you visit your physician, you simply make a small copayment. There are no deductibles or claim forms to worry about. And preventive services, such as annual physicals and Pap smears are provided free of charge.

The Out-of-Network side of the Freedom Plan provides you-with traditional type health coverage. When you seek medical care Out-of-Network, you will be responsible for paying a percentage of the covered expenses and an annual deductible. The Freedom Plan you select will determine the deductible, co-pay, and maximum out-of-pocket expenses.

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Oxford's Freedom Plan is like having a traditional fee-for-service plan and HMO type benefits all in one plan. You have the choice and flexibility either of visiting one of Oxford's Network Physicians or the freedom to go outside the Network and see any physician you wish.

When you visit one of the Network Physicians, you are receiving top-quality care from a board-certified or recently board-eligible physician. Board certification is the best measurement of a physician's expertise.

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Oxford believes that preventive care is the best route to keeping you as healthy as possible. So, your Freedom Plan coverage includes preventive services like annual physicals, Pap smears, mammograms and infant immunizations at no charge.

Oxford's goal is to work together with you and their Network Physicians to ensure you receive the care you need and to help you lead the healthiest lifestyle possible. Please remember that in order to receive full coverage for preventive services, you must receive the care through a Network Physician.

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Oxford realizes that the only way to provide Members with topnotch care, is to recruit only the best physicians. They have established the strictest requirements in their Service Area for allowing physicians into the Network. One hundred percent of their Roster of Network Physicians are:

• Board-certified or recently board-eligible if practicing less than five years. Only about half the doctors in the metro New York area meet this requirement.
• Checked to ensure they have hospital admitting privileges that were never curtailed or revoked. If so, Oxford investigates why the privileges were reduced or removed. If they believe there is cause for concern, the physician will not be admitted to the Network.
• Visited by an Oxford Representative to make sure that the office and staff meet Oxford's standards of courtesy, comfort, cleanliness and professionalism.
• Reviewed to ensure that their physician license and malpractice insurance are current.

To ensure physicians continue to meet Oxford's strict standards, they re-credential each of their Network Physicians every two years.

Oxford also strives to maintain true partnership relationships with their providers. Their physicians are involved in creating their policies and procedures. And they always are provided with current information on the best and most appropriate medical practices, so they can deliver high-quality care.

Once physicians enter the Oxford Network, their performance is continuously monitored through their Quality Management Medical Advisory board. The board reviews medical cases, sets physician recruitment requirements, establishes medical policies and monitors the appropriateness of care provided to patients.

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If you are traveling outside the Oxford Service Area, you are covered under the Out-of-Network portion of your plan. You will be required to submit claim forms, and pay a percentage of your covered expenses and an annual deductible.

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Although cost savings are increased through In-Network services, Oxford realizes that you
may desire the freedom to visit the physician of your choice. That's why the Freedom Plan covers you even when you visit an Out-of-Network physician.

Remember, though, that when you do seek care outside the Oxford Network, you will be responsible for paying a higher portion of your medical expenses, including an annual deductible.

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Oxford works hard to keep claims processing as simple and quick as possible, so you are reimbursed in a timely fashion. Reimbursement checks normally are sent within 15 business days after the completed claim is received.

• Please remember the following:
• Send the original claim to Oxford and keep a copy for your records.
• Fill out the claim form completely and legibly. The most common obstacle to smooth claims processing is a missing Member I.D. number or a missing bill.
• The claim form must be signed by either the patient or the subscriber.
• Enclose an Itemized bill including a complete description of each service, and a breakdown of the charges. It must contain:
• Patient name and Oxford Member I.D. Number.
• Name and address of provider making charge
• Date of service
• Type of service
• Description of service or CPT-4 code
• Individual charge for each service
• Diagnosis or symptoms

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Oxford fully covers medical emergencies worldwide.

You are responsible only for a small co-payment for an emergency room or office visit (see your group's Summary of Benefits for the amounts). However, this co-payment is waived if you are actually admitted to a hospital.

All that is required is that you call Oxford's Medical Management Department at 800-444-6222 within 48 hours of your emergency treatment (or as soon as you are physically able), so Oxford can make sure you receive appropriate follow-up care. If you or a representative do not call Oxford within the required time, your coverage may be denied.

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Hospital coverage is limited to a semi-private room, intensive care or coronary unit accommodations. Psychiatric hospital care is subject to limits that are detailed in your group's Summary of Benefits.

Remember, you will be covered for non-emergency care only if your In-Network Physician, or you, if you are seeing an Out-of-Network physician, obtain pre-certification from Oxford. When you call Oxford, make sure you specify the doctor and hospital you are using, so they can help maximize your coverage.

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Oxford has contracted with Quest Diagnostics, a leading medical laboratory, to provide complete coverage for any lab tests you require. Whether your tests are ordered by an In- or Out-of-Network Physician, Oxford will pay the entire cost of the service if performed by Quest.

Radiological tests prescribed by an Oxford Participating Physician are also covered 100% when performed by one of their Participating Radiological Centers.

All tests conducted by labs other than Quest Diagnostics and all Out-of-Network radiological services are covered as Out-of-Network expenses.

If you are using an Out-of-Network physician, make sure to ask that he/she uses Quest Diagnostics when ordering diagnostic lab tests for you, so you still receive 100% coverage for lab services.

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1. The subscriber's spouse
2. Any unmarried child who is under the age of 19.
3. Any unmarried child is eligible up to age 25 years of age provided the child is a full-time student in an accredited educational institution. A Student Verification Form will be mailed to each member who has a dependent between age 19 and age 25.

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Primary Care Physician Plan (Gatekeeper Plan) Answers

When your Network Physician feels you should obtain a procedure requiring pre-certification, he/she must contact Oxford's Medical Management Department at 800-444-6222 at least 14 days in advance. If an Out-of-Network physician recommends a procedure requiring pre-certification, you must call medical management to pre-certify.

One of Oxford's Medical Management Representatives will examine your case, consult with your physician and determine the scope of your coverage.

Although it is your PCP's responsibility to contact the Medical Management Department for procedure pre-certification, Oxford suggests that you contact Medical Management as well, because if a procedure is not pre-certification, your coverage may be denied.

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Oxford's Physician Network includes highly-qualified, board-certified or recently board-eligible specialists in every field of practice who are dedicated to providing you with top quality specialized care.

However, in the rare case that a medically necessary service is not available through an Oxford Physician, with Oxford's approval, you can refer yourself to an outside specialist at no extra cost to you.

Remember that under the Freedom Plan, you do have the option to visit a specialist outside the Oxford Network at any time. If you do so, those expenses will be covered as an Out-of-Network benefit, and you will be responsible for filing a claim, and paying an annual deductible and a portion of the medical expenses.

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If you are admitted to the hospital by your physician, your hospital care expenses are covered 100%. You do not have to worry about claim forms or deductibles. However, if you are admitted by an Out-of-Network physician, the care will be covered as an Out-of-Network expense. You will be responsible for paying deductibles and coinsurance.

Remember, that when your physician recommends hospitalization or an outpatient procedure at any hospital facility, the services will be covered only if they are reviewed and pre-certified by Oxford's Medical Management Department. Pre-certification also is required for all surgical or major diagnostic procedures regardless of where they are performed.

If you are unsure whether a particular procedure requires pre-certification, call Oxford's Medical Management Department at 800-444-6222. Their Medical Management Representatives are available to discuss with you whether pre-certification is necessary.

Oxford's medical review and pre-certification processes are designed to protect you from unnecessary surgeries, to ensure that you are receiving appropriate medical care, in an appropriate setting, and to allow you the greatest benefit from your Oxford coverage.

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Each member of your family has the right to select a different PCP if he/she wishes. And, since Oxford feels it is necessary for women to obtain regular gynecological care, they encourage women to select an OB/GYN in addition to their PCP and to visit their OB/GYN without a referral.

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You may see your PCP as often as you feel necessary. However, to be covered In-Network, you may visit an Oxford Specialist only when your PCP provides you with an authorized specialist referral.

When your PCP signs a referral for you, the doctor will specify a certain number of visits to the specialist If you choose to exceed the number of appointments, or visit a specialist without a referral, the visits will be covered as an Out-of-Network expense. You will be required to submit claim forms and pay an annual deductible and a percentage of your medical expenses.

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The Oxford Freedom Plan was built on a foundation of flexibility and choice. You always have the option of changing your PCP at any time by simply calling their Customer Service Department at 800-444-6222. You either can speak to a Customer Service Associate (CSA) to change your PCP, or use the telephone Interactive Voice Response system to change your PCP at the touch of a button.

As soon as you call, the change is processed, and you may schedule an appointment with your new PCP right away. Within a few days, you will be sent a new Oxford Member I.D. card reflecting the change.

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