Nova Pathfinder gives you the freedom to choose your primary care; this includes using a Chiropractor as your primary care provider.
Will you pay less if you use a preferred provider?
Yes. This plan uses a Preferred Provider network defined as a health care provider or group of providers who have contracted to deliver specified covered services. Nova Pathfinder has contracted with a network of Preferred Providers to arrange at a lower rate in return for prompt payment. Our network or (Preferred Providers) accept the Allowed Fee schedule amount as payment in full and will not balance-bill our insured members. This contract allows Preferred Providers to offer you lower-cost services than providers not in our network. If the provider does balance-bill, it is an agreed-upon rate that the Member is made aware of before services because there is a Pre-authorization or a Single-case Agreement in place for the services. Nova always suggests that Members work with our Claims department and Pre-authorization teams to shop for the best price for the service to be provided. Be aware; your Preferred Provider network might use a Non-Preferred Provider for services such as lab tests.
*Check with the Nova Benefits department before you get services.
If your provider is not on our Preferred Providers’ list, we are happy to work with them to get them into our Providers’ list. Any licensed health care provider in good standing and in a class approved by the health care corporation can become a Preferred Provider with Nova Pathfinder HealthCare. According to the National Conference of State Legislatures, more than half of the states in the U.S. operate under “Any Willing Provider” statutes, also known as “Any Authorized Provider,” which require health insurance carriers to allow health care providers to become members of the carriers’ network of providers if certain conditions are met. These laws prohibit insurance companies from limiting the membership of network providers based on geography or other characteristics. Still, the health care provider must meet specific requirements for network membership made by the insurance company. Of course, these laws vary by state and scope. For a summary of Any Willing Provider statutes by state, visit the NCSL website.
Nova Pathfinder invites all Naturopathic, Complementary, Integrative, Holistic Dentists, Functional Medicine Practitioners, and all Conventional Practitioners to apply for membership to become a Preferred Provider in our network. Please review our Preferred Providers terms before filling out an application.
Non-Preferred Providers (Also part of the open network) Any Provider that is not a Preferred Provider is considered a provider who doesn’t have a contract or will not accept a single case agreement or accept the Nova fee schedule included in a Pre-authorization provide services. The plan covers Non-Preferred Providers; however, you’ll usually pay more to see a Non-Preferred Provider than with a Preferred Provider. Nova also refers to these providers as “non-participating.”
When a provider bills you for the balance remaining on the bill that your plan doesn’t cover, this amount is the difference between the actual billed amount and the allowed amount. For example, if the provider charge is $200 and the allowed amount is $110, the provider may bill you for the remaining $90. This happens most often when you see a NON-Preferred Provider. You will pay the most if you use a non-preferred provider’s open network. You may receive a bill from a provider to differentiate between the provider’s charge and what your plan pays. This is called balance-billing.
- To avoid balance-billing, be sure to obtain a Pre-authorization first, especially for amounts exceeding $300.
- If your provider includes holistic/naturopathic providers, their orders and referrals may consist of “over-the-counter” supplements and essential oils. These may be covered as an allowed benefit if the Wellness treatments & Services guidelines are followed for coverage limits.
Do you need a Referral/Pre-authorization to see a specialist?
Yes, a Referral and Pre-authorization are required from your primary care provider to see a specialist. (This includes holistic/naturopathic providers.) If the specialist needs to provide additional services, those services will also need Pre-authorization.
Primary Care Annual Wellness Visit
Members are reimbursed up to $150 for two yearly visits, starting after three months of membership, up to $150.00 for each visit or one combined visit for a total of $300 annually. Any additional cost over the $300 is applied toward the deductible and paid by Member.