Member Frequently Asked Questions

1. May I choose my own doctor?
   
   
2. Do I need a referral form or pre-approval to see a specialist?
   
   
3. How will my physician or hospital know I am a SOUTH CENTRAL Preferred member?
   
   
4. Do any services/procedures need to be pre-authorized/pre-certified?
   
   
5. What services are covered by SOUTH CENTRAL Preferred?
   
   
6. Will I receive an "explanation of benefits” after my claims has been processed?
   
   
7. What is SOUTH CENTRAL Preferred's relationship with my third party administrator (TPA) or payor?
   
   
8. What is an "allowable fee"?
   
   
9. I don't have a SOUTH CENTRAL Preferred I.D. card. How do I get one?
   
   
10. How do I submit a medical claim to SOUTH CENTRAL Preferred?
    
    
11. Where should I send my dental and/or prescription claims?
    
    
12. I have a claim that was denied or paid incorrectly. Who should I talk to?
    
    
13. Is my doctor a participating SOUTH CENTRAL Preferred provider?
    
    
14. What is COBRA and how does it effect me?
    
    
15. What is a Third Party Administrator (TPA)?
    
    
16. What coverage do I have when I am traveling outside of Central Pennsylvania?
    
    
17. What is a diagnosis and why is it needed to pay my claim?
    
    
18. SOUTH CENTRAL Preferred sent me an accidental injury form. Why?
    
    
19. I received a coordination of benefits letter. Why?
    
    
20. I believe my claim was paid/denied improperly. How do I have this reviewed?
    
    
21. I am receiving care as the result of an automobile accident. The benefits provided by my automobile insurance have run out. How do I submit future claims to SOUTH CENTRAL Preferred?
    
    
22. I need to add a new dependent to my coverage. What do I need to do?
    
    
23. What is a pre-existing condition and how does it effect me?
    
    
24. What is a co-pay? What is co-insurance?
    
    
25. Where can I find the Authorization for Release form?
    
    

1. May I choose my own doctor?

YES! You may choose any provider listed in our Provider Directory or a provider that is not listed. If you select a provider who is not listed in the SOUTH CENTRAL Preferred Provider Directory, your employer may require you to pay more "out-of-pocket" expense for your care. You should check with your employer or TPA if you have questions about your benefits. If you are unsure which TPA your employer uses, please refer to your identification card.

2. Do I need a referral form or pre-approval to see a specialist?

NO! You may see the specialist of your choice at anytime. If you select a specialist who is not listed in the SOUTH CENTRAL Preferred Provider Directory, your employer may require you to pay more "out-of-pocket" expense for your care. You should check with your employer or TPA if you have questions about your benefits. If you are unsure which TPA your employer uses, please refer to your identification card.

3. How will my physician or hospital know I am a SOUTH CENTRAL Preferred member?

Your employer or TPA will provide you with an identification card that displays our logo. Please show this card any time you are seeking healthcare services.

4. Do any services/procedures need to be pre-authorized/pre-certified?

SOUTH CENTRAL Preferred requires all participating providers to pre-certify selected services for you. When you use a participating provider, you are not required to pre-certify any service. If you use a non- participating provider your employer may require you to pre-certify certain services. You should check with your employer or TPA if you have questions about your benefits. If you are unsure which TPA your employer uses, please refer to your identification card.

5. What services are covered by SOUTH CENTRAL Preferred?

Covered services are listed in the benefit plan your employer has designed. You should check with your employer or TPA if you have questions about your benefits. If you are unsure which TPA your employer uses, please refer to your identification card.

6. Will I receive an “explanation of benefits” after my claim has been processed?

Yes. Your Third Party Administrator (TPA) will mail you an explanation of benefits which details what the provider charged, what was approved, what was paid and what you owe the provider. If you are unsure which TPA your employer uses, please refer to your identification card.

7. What is SOUTH CENTRAL Preferred's relationship with my third party administrator (TPA) or payor?

SOUTH CENTRAL Preferred, a PPO, manages the delivery of your health care. Our recommendations will be given to your providers and your TPA. Final authority for determining what services are covered under your employer's benefit plan resides with your TPA. Our recommendations focus on determining the appropriate level and setting for your care. If you are unsure which TPA your employer uses, please refer to your identification card.

8. What is an “allowable fee?”

SOUTH CENTRAL Preferred has contracts with all participating providers. These providers agree to provide their services to our members for a negotiated price. We call this price the "allowable fee". When using a participating provider, you are never billed more than the allowable fee for their services.

9. I don't have a SOUTH CENTRAL Preferred I.D. card. How do I get one?

Identification cards are issued by your TPA. Please contact them if you need an identification card. If you are unsure which TPA your employer uses, please refer to your identification card. If SOUTH CENTRAL Preferred is your TPA, you may send us an E-mail requesting a new identification card.

10. How do I submit a medical claim to SOUTH CENTRAL Preferred?

If you have SCP as primary coverage and you use participating providers, they should always submit your claim for you. If you have SCP as secondary coverage, you may have to submit the claim yourself to SCP. If you use a non-participating provider or need to submit an SCP secondary claim, please submit his/her itemized bill, with your member I.D. number printed next to your name. Our mailing address is P.O. Box 2347 York, PA 17405.

11. Where should I send my dental and/or prescription claims?

Each of our employers determines how dental and prescription claims are handled for their employees. Please contact your Personnel/Human Resources Department for an answer to this question.

12. I have a claim that was denied or paid incorrectly. Who should I talk to?

Your TPA is responsible for the payment or denial of claims. Please contact them to discuss these issues. If you are unsure which TPA your employer uses, please refer to your identification card.

13. Is my doctor a participating SOUTH CENTRAL Preferred provider?

SOUTH CENTRAL Preferred's network of providers is the most comprehensive in our area. To find out if a specific provider participates in our network click here and you will go to our on line provider directory.

14. What is COBRA and how does it effect me?

COBRA is a federal law that was passed in 1985. It allows certain individuals to continue to receive benefits under employer-sponsored health plans even after those individuals are no longer employed by that employer. To find out if you qualify for COBRA benefits contact your Personnel/Human Resources Department.

15. What is a Third Party Administrator (TPA)?

Employers who offer healthcare benefits to their employees have two options. They can buy insurance from an insurance company or they can provide the benefits themselves and hire a company to administer their benefit plan. A TPA is a company that administers benefits for self funded companies. Administration normally includes interpreting the benefit plan, adjudicating claims, paying providers and answering employee questions. SOUTH CENTRAL Preferred functions as a TPA for several employers. If you are unsure which TPA your employer uses, please refer to your identification card.

16. What coverage do I have when I am traveling outside of Central Pennsylvania?

All of our employer groups provide some coverage for their employees when they travel outside of central Pennsylvania. To learn more about your coverage contact your TPA. If you are unsure which TPA your employer uses, please refer to your identification card.

17. What is a diagnosis and why is it needed to pay my claim?

Your diagnosis tells your TPA the reason that you needed health care. This is very important because some benefit plans pay at different levels based on your diagnosis.

18. SOUTH CENTRAL Preferred sent me an accidental injury form. Why?

We are the TPA for your employer and the diagnosis on your claim caused us to issue this letter. Sometimes another type of benefit should pay before your health care pays. Please complete the form and promptly mail it back to us. This will allow us to process your claim as quickly as possible. If you prefer, you may complete an on-line accidental injury form.

19. I received a coordination of benefits letter. Why?

We are the TPA for your employer. Once a year we need to check and see if you have health care benefits available from any other source. We need to make sure that if you have multiple coverages it works correctly. Please complete the form and promptly mail it back to us. This will allow us to process your claim as quickly as possible. You may complete an on-line coordination of benefits form.

20. I believe my claim was paid/denied improperly. How do I have this reviewed?

Any review or appeal must be conducted by your TPA. If you are unsure which TPA your employer uses, please refer to your identification card. If SOUTH CENTRAL Preferred is your TPA please send us a written description of the problem and how you believe it should be resolved. We will review the issue, consider the information you provided and provide you with our written response. If you would like to use E-mail to inform us of an issue, please click here.

21. I am receiving care as the result of an automobile accident. The benefits provided by my automobile insurance have run out. How do I submit future claims to SOUTH CENTRAL Preferred?

Your automobile insurance should have sent you a letter indicating that your benefits are now exhausted. Send us a copy of this letter with your next claim. As you visit providers in the future, please indicate to them that your coverage is now under SOUTH CENTRAL Preferred. Our mailing address is: P.O. Box 2347 York, PA 17405

22. I need to add a new dependent to my coverage. What do I need to do?

You must contact your employer’s Personnel/Human Resources Department to add someone to your coverage.

23. What is a pre-existing condition and how does it effect me?

A pre-existing condition is a medical problem that you had before you were covered by your current benefit plan. Some benefit plans limit the amount of coverage available for pre-existing conditions. To learn more about your coverage contact your TPA. If you are unsure which TPA your employer uses, please refer to your identification card.

24. What is a co-pay? What is co-insurance?

Some benefit plans require the beneficiary to pay for a portion of his/her care. If the required payment is a dollar amount ($5, $10, $20, etc.) it is called a co-pay. If the required payment is a percentage of the cost (10%, 20%, Etc.) it is called co-insurance. To learn more about your coverage contact your TPA. If you are unsure which TPA your employer uses, please refer to your identification card.

25. Where can I find the Authorization for Release form?

Click on the Members tab. Click on Forms. Click on the link for the Authorization form. Print down the form, complete it and fax it to our Customer Service department at (717) 755-7190.