Northern Illinois Health Plan

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Northern Illinois
Health Plan

773 W. Lincoln Blvd.
Suite 402
Freeport, Illinois 61032
(815) 599-7050 or
(800) 723-0202

Employee FAQs

Q: 

What do I do in an emergency?

A:

In an emergency, always seek medical care immediately. Go directly to the nearest emergency facility or call 911. As Northern Illinois Health Plan participants, your plan provides emergency medical benefits for you and your family members anywhere, 24 hours a day, even when you're away from home.

An emergency is an accident or sudden illness that the average person believes needs to be treated right away or it could result in loss of life, serious medical complications or permanent disability.

Some examples of emergencies could include:

  • Seizure or loss of consciousness
  • Uncontrolled bleeding
  • Inability to breathe or shortness of breath
  • Poisoning or suspected overdose of medication
  • Chest pain or oppressive squeezing sensation in the chest
  • Numbness or paralysis of an arm or leg
  • Sudden slurred speech
  • Broken bones
  • Severe pain

Contact your Primary Care Physician following treatment so he can determine if follow-up care is needed and make any necessary referrals according to your plan guidelines.

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Q:

How do I file a claim?

A:

When you receive care from a participating doctor, specialist, hospital or lab, you don't need to file a claim form. Simply present your Northern Illinois Health Plan ID card and the health care provider will bill us. If you receive treatment with a provider who is not participating they may still bill us directly at the address listed on your card or you can file an itemized bill directly to our office. An itemized bill should include the provider's name address and phone number, a diagnosis for the service and specific procedures received. It should also include the patient's name, date of birth and ID number. No claim forms are required.

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Q:

If I have two insurance carriers, can I choose which plan is primary?

A:

There are standard guidelines that apply when someone has more then one group health plan. Determination of which plan is primary depends on the circumstances (i.e., employee or dependent, active or inactive, court ordered or custody rule for dependent children and age or disability). Your Summary Plan Description describes the order of benefits in detail in the Coordination of Benefits section.

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Q:

I lost my card; can I still see my doctor and fill prescriptions?

A:

During regular business hours the pharmacy can call our office at (800) 723-0202 for submission information. If it is not during regular business hours your pharmacy may have your information stored and will verify your identity with your driver's license. If they do not have your information stored then you should pay for the prescription and submit your full receipt for reimbursement. Contact our office or your human resources department for a replacement ID card.

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Q:

Do I pay the insurance carrier for my deductible and coinsurance?

A:

Always pay the provider of services. The provider's office will bill you directly after NIHP has paid the insurance portion or they may ask for payment at time of service for amounts that are your responsibility.

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Q:

Do I need special claim forms to submit a bill?

A:

You do not need special forms to submit claims. Your providers that are part of the NIHP network will bill our office for you. If you are traveling and are asked to pay up front for your services send us a copy of the itemized bill from the provider's office with the provider's name, address and telephone number. The services rendered should be itemized with diagnosis, procedure codes and billed charges. Submit your claim to: NIHP, P.O. Box 880, Freeport, IL 61032.

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Q:

Who do I notify of a change of address?

A:

To change your address log on to https://secure1.nihp.com. Select "Address" under the "CHANGES" section in the left hand column of the EMPLOYEE CONTROL PANEL. You can also contact our Customer Service Department at (800) 723-0202 option 1 on your touch-tone phone. Messages with this information can be left on our confidential voicemail 24 hours a day 7 days a week. Include your name and ID number for identification purposes.

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Q:

Who do I contact regarding my benefits?

A:

Please refer to the phone number on the back of your card for Customer Service. The Northern Illinois Health Plan can be reached at (800) 723-0202 option 1. Our office is open Monday through Friday 8:00 a.m. to 5:00 p.m. CT. You can also email our office by logging on to https://secure1.nihp.com. On the EMPLOYEE CONTROL PANEL choose the "Contact Us" option under INFORMATION.

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Q:

What providers are in my network?

A:

Your network of providers will differ depending on your employer's plan design. You may refer to your Summary of Benefits or contact Northern Illinois Health Plan to confirm your provider of service is participating with your network. Log on to https://secure1.nihp.com to send an email or call us at (800) 723-0202 option 1. Our office is open Monday through Friday 8:00 a.m. to 5:00 p.m. CT.

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Q:

How much of my deductible and out-of-pocket have been met for this calendar year?

A:

To verify how much of your deductible and out-of-pocket have been met you can log on to https://secure1.nihp.com 24 hours a day, 7 days a week. On the EMPLOYEE CONTROL PANEL choose "Claims" under INQUIRY. Family totals are only housed under the Employee's accumulators (=). All other individual totals are listed under specific member's accumulators (=). You can also call us at (800) 723-0202 option 1. Our office is open Monday through Friday 8:00 a.m. to 5:00 p.m. CT.

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Q:

How do I know if I have any benefits still available for a service with a calendar year, and or lifetime maximum payable? I.E.: Chiropractic, Dental, Orthodontia, Preventative, Behavioral Health etc.

A:

To verify how much of a limited benefit has been used you can log on to https://secure1.nihp.com 24 hours a day, 7 days a week. On the EMPLOYEE CONTROL PANEL choose "Claims" under INQUIRY. Individual totals are listed under each specific member's accumulators (=). You can also call us at (800) 723-0202 option 1. Our office is open Monday through Friday 8:00 a.m. to 5:00 p.m. CT.

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Q:

How do I receive reimbursement from my Flexible Spending Account?

A:

When enrolling for a Flexible Spending Account you may choose to have automatic rollover. This option will automatically reimburse you for any out of pocket amounts you incur when your claim is processed through NIHP. If you do not choose this option, call our office at (800) 723-0202 or fax at (815) 599-7059 to request reimbursement forms.

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Q:

What services/items are eligible for reimbursement through my Medical Flexible Spending Account?

A:

Flexible Spending Account (FSA)

Eligible Expenses:

  • Dental services (non-cosmetic)
  • Orthodontia
  • Eye exams
  • Eyeglasses/contact lenses
  • Prescription sunglasses
  • Hearing aids and batteries
  • Lab exams/tests including x-rays
  • Crutches, walkers, wheelchairs
  • Medical procedures/services
  • Prescription medications

Ineligible Expenses:

  • Cosmetic surgery/procedures
  • Electrolysis
  • Tattoo removal
  • Over-the-counter (unless prescribed by a physician in accordance with current laws)
  • Personal hygiene products (shampoo, lotion, deodorant)

These are not "all-inclusive" lists. For a complete summary of eligible items, see IRS Publication 502.

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Q:

What are Reasonable, Usual and Customary Charges?

A:

Reasonable and customary charges are amounts charged by health care providers that are consistent with charges in a given locale. The reason charges are held to a reasonable and customary standard is to be able to provide a benefit for non-contracted providers without paying for excessive charges. Reasonable, usual and customary fees are provided to our office by a company that specializes in the collection of this data.

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Q:

When do I need prior approval (pre-certification) for services

A:

Prior approval, or pre-certification, requirements are plan specific. Normally scheduled inpatient services, outpatient procedures such as MRIs, outpatient surgeries or endoscopic procedures, home health care, physical, occupational and speech therapies, and durable medical equipment require precertification. However, this is specific to your employer group so check your card or plan document. You can also contact our office Monday through Friday 8:00 a.m. to 5:00 p.m. CT or email us at https://secure1.nihp.com.

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Q:

What should I do if a claim is denied?

A:

If you believe a claim has been denied in error, first call Customer Service at (800) 723-0202 option 1. Our Customer Service Professionals will review your claim for you and if they cannot resolve the situation on the phone call they will research your issue and get back to you normally within 48 hours. If this still does not resolve your concerns, then you can send a written Appeal to our office for review by the Northern Illinois Health Plan Appeal Committee.

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Q:

What is a Preferred Provider Organization (PPO)?

A:

A Preferred Provider Organization (PPO) is an organization of medical providers delivering health care on a discounted, fee-for-service basis. "In-Network" refers to those providers who have contracts with the PPO. "Out-of-Network" refers to all providers who do not have contracts with the PPO.

Plan participants have a choice of using in-network providers or out-of-network providers. Choosing an in-network provider generally results in lower co-payments, deductibles and coinsurance charges. Both the member and the employer can realize substantial savings by using in-network providers.

If services are received from an out-of-network provider, generally the Plan will cover the services, but at a reduced reimbursement level, subject to the Reasonable, Usual and Customary charges.

PPOs are one of the most flexible forms of managed care, providing savings and allowing the employee the option of receiving care from any provider.

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