Will I need to show my Saint Mary’s membership ID card when receiving care?
Your Saint Mary’s Health Plans membership ID card contains important information, including the office visit copayment and your subscriber ID number. Anytime you need medical care, including specialist care or emergency care, you will be asked for your Saint Mary’s membership ID card.
If you do not receive your member ID card within two weeks of enrollment, please contact Member Services at:
HealthFirst HMO Members – 775.770.6060 or 800.863.7515
Health Choice PPO Members – 775.770.6900 or 800.433.3077
What do I do if I lose my membership ID card?
Saint Mary’s will send a replacement card to your home address within 7 to 10 working days of your request.
How do I report an address change?
To ensure continuous health care coverage, Saint Mary’s must have your correct contact information, including address and telephone number. We notify members by mail about any referrals, program or physician changes, and claims status. Plus, we want to ensure that you receive issues of our member newsletter.
Please complete an Enrollment Application/Membership Change Form from your Human Resources Department, call our Member Services at 775.770.6060 (HMO members) or 775.770.6900 (PPO members) before you move, or mail us a change of address card available at your local post office.
How do I find a Saint Mary’s Health Plan physician?
Saint Mary’s Health Plans comprehensive network of physicians and specialists are all detailed in the provider directory. Click here to log-in to the secure member portal and search for providers within your network.
What is a deductible?
This is the amount you pay for specified covered services before the plan begins to pay. Deductible amounts are listed in your Summary of Benefits and are based on a calendar year accumulation, not plan year.
What is coinsurance?
This is a percentage of covered eligible medical costs that you pay for most covered services after you have received care and your claim has been processed. Coinsurance begins once you have satisfied your plan deductible. Your coinsurance is listed in your Summary of Benefits.
What is a copayment?
This is a fixed dollar amount you pay for certain services when you receive care. Copayments are listed in your Summary of Benefits and on your Saint Mary’s Health Plan membership ID card. Copayments may or may not apply toward your out of pocket costs depending on your plan design. Please see your Summary of Benefits for clarification.
What is an Out-of-Pocket Maximum?
There is a limit to the total amount of coinsurance and/or any plan deductibles you have to pay each calendar year. This is called your Out-of-Pocket Maximum (OOPM). Copayments do not accumulate towards your OOPM. To find out what your specific benefits are, refer to your Summary of Benefits.
How do I enroll?
What about my dependents?
Check with your Employer about how and when they handle your Saint Mary’s Health Plans enrollment. If you have a change in your family status and need to add eligible dependents, remember that you typically have 31 days to add new members to your plan. Your employer can advise you about the necessary forms to complete.
What is the role of my Primary Care Physician (PCP)?
If you are an HMO member, your Primary Care Physician’s essential responsibility is to provide, arrange and coordinate all aspects of your health care. Your PCP is to act as your personal doctor. When you need care, call your PCP. If you need to go to the hospital or see a specialist, your PCP will make a referral. In the case of an emergency, visit the ER immediately; you do not need to contact your PCP first.
Do PCPs have the same medical backgrounds or do they have special training?
Generally, they are medical doctors who specialize in certain fields, including:
Family/General Practitioners – doctors who treat patients of all ages.
Internists (internal medicine) – doctors who treat adults and may have a sub-specialty.
Pediatricians – doctors who treat children.
How can I change my PCP?
You can change your PCP anytime. To do so, simply contact Member Services:
- Phone 775.770.6060 or 800.863.7515
- Fax 775.770.3820
Can my spouse and children have a different Primary Care Physician than I have?
Yes. Each family member with Saint Mary’s coverage may have his or her own PCP. A general or family practitioner, internist or pediatrician may serve as a PCP.
What if I need hospital care?
Your primary care physician will handle the care you need and will arrange for any non-emergency hospital admissions.
What if I am traveling and need emergency medical care?
No matter where you are, anywhere in the world, if you need emergency medical care, call 911 (in areas where the system is established and operating) or go to the nearest emergency facility. If you are traveling outside of your service area, you may have to pay for your treatment and then complete a claim form to get reimbursed.
You and your family are covered by Assist America, free of charge, through Saint Mary’s Health Plans. Assist America is a global emergency service that connects you to doctors, hospitals, pharmacies and other services if you experience a medical emergency while traveling 100 miles or more away from your permanent residence or in another country.
Your Assist America ID card and more details about the benefit program can be found within the Saint Mary’s Health Plans new member packet. For additional information about the program or if a new ID card is needed, contact 800.433.3077.
What is urgent care and when should I use it?
Urgent care is for medical situations that are serious, but not life-threatening. Saint Mary’s Health Plans has urgent care centers in our network of providers. If you are in need of medical attention and your primary care physician is not available, and urgent care is a better alternative than using the emergency room. Urgent care is used for the treatment of non-emergency illnesses or injuries such as:
- Bronchitis or sore throats
- Ear infections
- Simple lacerations
- Sprains and strains
To find out which facilities are in the network, click here.
What services need to be pre-approved by Saint Mary's Health Plans?
In order to maintain quality and medical management standards, the services provided to our members are continually evaluated. To ensure that the medical community is providing accurate and necessary care, SMHP requires pre-approval for certain services for both HMO and PPO plans. Such pre-approval is referred to as Prior Authorization.
Prior Authorization is the standard industry process of receiving approval for certain procedures and medical services. Your PCP or specialist obtains this on your behalf. For a specific list of services that require pre-approval within your plan, click here.
How are prescriptions covered?
If your Saint Mary’s Health Plans coverage plan includes prescription benefits, you must have a pharmacy within the network fill your prescriptions to ensure that you receive the best rates (refer to your Provider Directory for a list of participating pharmacies).
Saint Mary’s Health Plans partners with Catalyst Rx to provide your pharmacy benefits. For additional information about how a certain drug may be paid, please contact Catalyst Rx member Services Department at 866.358.9534 with questions regarding your prescription drug plan. Representatives are available 24/7 to assist you. Or simply log on to www.catalystrx.com and enter the member information located on the back of your Saint Mary’s Health Plans member ID card.
For more information about SMHP Pharmacy benefits, click here.
How do I find out my pharmacy copay?
Pharmacy copayments are listed in your Summary of Benefits, which are included in the member book you will receive after enrollment. The pharmacy benefit will include copayments for both brand name and generic prescriptions. If you have any questions about the summary of benefits information, please call member services at:
HealthFirst HMO Members – 775.770.6060 or 800.863.7515
Health Choice PPO Members – 775.770.6900 or 800.433.3077
Each time your doctor writes a prescription, we encourage you to visit www.catalystrx.com. You will find several useful tools like:
- Catalyst Price and Save which allows you to determine a drug copay and if the prescription requires Step Therapy or Prior Authorization.
- Brand name Generic equivalents.
- Locate a participating Pharmacy.
For more information about SMHP Pharmacy benefits, click here.
Can I find my eligibility and benefit information online?
Yes, Online Member Services provides an efficient way for you to access an electronic copy of your Summary of Benefits.
What is the 24-hour NurseLine?
All SMHP members have FREE access to a registered nurse 24/7 through the NurseLine. Our team is staffed with registered nurses and is backed by a sophisticated software system that uses the most current, reliable set of clinical guidelines. Nurses assist you in determining the safest, most appropriate level of care for your needs, including self-care steps for symptoms, accidents or general health-related questions.
To reach the 24-hour NurseLine, call 800.243.5495.
Now available! Online Question Submissions
Saint Mary's Health Plan members can now submit health or medical questions online by visiting our secure member portal. A nurse will evaluate your request and send an email reply with relevant information within 24 hours.
Click here to log-in to our member portal and submit a request for information.
How do I know if I have dental and/or vision coverage?
SMHP members do not have separate ID cards for dental and vision benefit coverage. If you have such coverage, your SMHP member ID will have “Dental” and/or “Vision” imprinted on the card. For a list of covered providers within the network, please call Member Services at the number printed on the back of your ID card.
What is the Member Travel Reimbursement program?
The Member Travel Reimbursement program is intended to offset the cost of travel for patients and/or their support person or family members for SMHP members who fully utilize tertiary care at the prestigious network facilities in Utah. This travel benefit applies only to expenses incurred related to tertiary evaluation and/or treatment. Tertiary facilities currently include University of Utah Medical Center, Intermountain Healthcare facilities and providers and Primary Children’s Hospital in Utah.
All trips and means of transportation must be approved by a SMHP Case Manager prior to commencing the trip. The member travel allowance (related to a single episode of care) totals $3,000. The allowance will reimburse living expenses (see below) up to a daily maximum of $200 per day with a trip maximum (related to a single episode of care) of $2,000. In addition, travel expenses (see below) will be paid up to $1,000 per trip (related to a single episode of care).
Covered Travel Expenses include:
- Airfare for patient and one support person (primary caregiver) or both parents if patient is a dependent.
- Rental car and mileage allowance for mileage recorded on the rental car receipt.
- Mileage, if member is driving /driven from home will be paid from the patient’s home to the University of Utah and back.
Covered living expenses include:
- Lodging expenses
- Meals for the patient and support person/caregiver or parents For a Travel Reimbursement form for tertiary care received at network facilities in Utah, contact SMHP Medical Management at 775.770.6211.
