McLaren Health Plan
McLaren Health Advantage (McLaren Employee Plan)

If you receive a statement showing a balance owed for medical services, the statement is coming directly from your provider. MHA does not bill you for your copays, coinsurance or deductible amounts. MHA does send you an Explanation of Benefits (EOB) that details the amount of charges for health care services you have received, the amount we paid, the amount we denied and any copay, coinsurance or deductible you may owe. If a bill from your provider does not match the information on your EOB, you can either call Customer Service at (888) 327-0671, TTY 711, for an explanation of the charge, or you can call your provider.

If you receive covered services from an in-network provider, you should never have to pay for anything other than your copay, coinsurance and/or deductible amounts. If you do pay out of pocket, only services that are covered by MHA will be reimbursed. You will need to provide a copy of your itemized statement, which includes CPT codes, diagnosis codes and charge amounts for each service. The statement should also include the provider’s name, address, phone, tax ID number and NPI number. You must also show proof of payment. Once we receive all of the above items, your request for reimbursement will be reviewed for medical necessity. Processing can take up to 60 days from the date received. MHA will reimburse you at MHA's reimbursement rate, which may be less than the actual charge.

Direct Reimbursement Form

Please use the PCP Selection form or call Customer Service at 888-327-0671 (TTY: 711). Representatives can assist you and make sure the PCP you’ve chosen is accepting new patients. The change will be effective the first day of the month following notification to McLaren Health Advantage.

Learn more about Auto No-Fault PIP Qualified Coverage, contact your agent for specific questions related to selecting coverage. If you need information about your deductible and whether your coverage excludes auto accidents, call Customer Service at 888-327-0671, TTY 711.

There may be a time when you have to submit a claim for reimbursement. You can get a claim form from Human Resources or find it here.

Complete the employee portion of the form, answering all questions.

1. For McLaren Health Advantage reimbursements, attach bills for services rendered. All bills must show:
   • Employee’s name
   • Name of patient
   • Name, address, and telephone number of the provider of care
   • Diagnosis
   • Type of services rendered, with diagnosis and/or procedure codes
   • Date of services
   • Charges
   • Any amounts paid by the employee
2. Send the above to McLaren Health Advantage, G-3245 Beecher Road, Flint, MI 48532

Yes, once the patient has met all the criteria and information has been reviewed by our Medical Management department. Here is the criteria:

• Must be 18 years of age or older
• Your doctor has ruled out other treatable reasons you are overweight, such as hypothyroidism
• Six months successful (regular attendance and consistent weight loss) participation in a physician supervised weight loss program within the last two years. Program includes diet, exercise and behavioral modification.
• BMI greater than 35 with two uncontrolled medical conditions such as diabetes, sleep apnea not controlled by CPAP, high blood pressure not controlled by medication, uncontrolled high cholesterol or severe heart or lung disease
• BMI greater than 40 with or without medical conditions
• Must pass a psychological evaluation for bariatric surgery performed by a licensed independent behavioral specialist
• Be evaluated by a contracted multi-disciplinary facility, for example McLaren Bariatric Institute

All the above information will be sent to McLaren Health Advantage for medical necessity review by your doctor. If approved, an authorization number will be sent to your provider. If not approved, a denial letter will be sent to you and your provider.

Choose a provider from the MHA provider directory. Verify the provider is participating with McLaren Health Advantage rather than just “accepting” the insurance. Identify yourself as a member of McLaren Health Advantage when you make your appointment. Always present your McLaren Health Advantage ID card at every appointment.

When you choose a McLaren Health Advantage PPO physician or hospital, you receive quality care at a reduced cost. McLaren Health Advantage negotiates reduced fees for your benefit. This means that when you use McLaren Health Advantage PPO doctors and hospitals, you save money.

In-network means the provider or facility has a contract with McLaren Health Advantage. The provider or facility has agreed to provide services to you at a discounted rate, making in-network services your best cost-saving option.

You will have the lowest out-of-pocket costs if you seek urgent or emergency care from a McLaren employed or owned provider (domestic) or McLaren Health Advantage directly contracted provider.

If the services provided are rendered by a Secondary Network provider, you are protected from balance billing.

If the provider is out-of-network, you will have higher out-of-pocket expenses and services may result in balance billing.

Helpful tip! Call Customer Service prior to traveling. Representatives can help locate urgent and emergency care providers in our Secondary Network in the areas near where you will be which may help protect you from balance billing.

A copayment is a fixed amount you pay for a health care service. It is usually paid directly to the provider when you receive the service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled.

A deductible is the amount you are responsible to pay annually before McLaren Health Advantage starts to pay. Services with a fixed dollar copay, such as office visits and preventive care, are not subject to deductibles. Services from out-of-network providers may result in higher deductibles. If you receive services from both in-network and out-of-network providers, you will be responsible for both in-network and out-of-network deductible amounts if you have an out-of-network benefit.

A Primary Care Physician or PCP is your main physician and will work closely with you to coordinate your health care needs and send you to a specialist when medically necessary. Your PCP provides you with a “medical home” where your patient care record will be maintained. Each family member covered by MHA must choose a PCP who is in our network. You can find a list of in-network physicians here. You can choose doctors who specialize in family practice, internal medicine or pediatrics as your PCP. Women can choose an OB-GYN as their PCP.

Coinsurance is your share of the costs of certain health care services. It's figured as a percentage of the amount of McLaren Health Advantage’s reimbursement rate. You start paying coinsurance after you've paid your plan's deductible. If you have an out-of-network benefit, coinsurance amounts may be higher when you receive services from out-of-network providers, and if you receive services from both in-network and out-of-network providers, you will be responsible for both in-network and out-of-network coinsurance amounts

Under the Affordable Care Act, there are certain in-network preventive services that are covered at 100 percent, where you pay no copayments or deductibles. A few examples are certain immunizations for children and adults and screening mammograms. The federal government changes these requirements often. For information on current preventive services, please visit www.healthcare.gov/coverage/preventive-care-benefits/. You may also refer to your Benefit Booklet or call Customer Service at 888-327-0671, TTY 711.

MHA has placed a prior authorization (PA) restriction on certain medications within the drug formularies. PA means the medication requires special approval before it will be considered for coverage by MHA. A medication may require a PA due to safety concerns or to ensure a more cost-effective formulary alternative cannot be used. If a prescribing provider feels a medication that requires a PA is medically necessary, then a Prior Authorization Form should be completed by the prescribing provider and faxed to the number indicated on the form. Please contact Customer Service at 888-327-0671, TTY 711, if you have any questions regarding the PA process or the status of a PA request.

Note: If you are in need of an emergency supply of a medication that requires prior authorization, please contact Customer Service at 888-327-0671, TTY 711, for assistance.