Member FAQ

Who is Evolutions Healthcare Systems (EHS)?

EHS is one of the largest independently owned Preferred Provider Organizations (PPO) in the United States. We contract with Hospitals, Physicians, and Ancillary providers to create a superior network of healthcare professionals that strive to deliver exceptional service at extremely competitive rates. For additional information see About Us

Is EHS an Insurance Carrier or Third Party Administrator?

EHS does not underwrite risk or administer health plans. To verify benefit information, contact your insurance company or plan administrator.

How do I use my EHS Network?

When you need medical care, simply visit our website and choose a provider through our online Provider Search. Call the selected physician´s office or hospital to arrange for an appointment and identify yourself as an EHS Network member. When you arrive at your appointment, be sure to present your group identification card. Depending on the benefit plan determined by your employer, you may be responsible for office visit co-pay at the time of service. Co-payment and deductible information can be easily found on your member ID card.

Does EHS have national network coverage?

EHS provides access to more than 300,000 providers through our Prime Network, Prime Plus Network, Select Network, and Select Plus Network covering all 50 states, District of Columbia and Puerto Rico. Up-to-the-date information on specific Providers may be obtained using our Provider Search. Since the EHS database of national Providers is extensive and your provider network is constantly developing, please be sure you are choosing the correct Group to start your search for the best results. This will ensure that the Provider you choose is participating in our network before you receive services.

Who do I call to verify my benefit coverage and/or co-pay amounts?

EHS is a managed care company. We are not a health plan or an insurance company and do not pay health claims. As such, EHS makes no determination regarding eligibility, benefits or covered services. To verify benefit information, please consult the number listed on your ID card, or refer to the beginning of your customized network directory (under Find a Provider), or  contact your human resources department for assistance.

How can I verify if my healthcare provider (physician/hospital) is in the EHS network?

Although you have the option to choose a non-participating Provider for care, you are encouraged to choose a participating Provider to minimize your out-of-pocket expenses. To verify that a provider is in network, you can use our Provider Search to create your own Custom Directory or contact Member Services for personal assistance in finding the right provider for you.  For Providers who are out of the network, the difference in cost to you can be substantial. Please contact your insurance company or plan administrator for benefit information regarding out-of-network providers.

My Provider is not listed in the directory or is not in network. What should I do?

To nominate a Provider for the EHS network, simply complete our Provider Nomination form, or contact Member Services

My Provider is listed in the directory, but says he/she does not participate. What should I do?

If you are visiting your Provider and are informed that they are not in the EHS Network, ask to use their telephone and contact Member Services. A Member Service Representative will gladly speak with the provider's staff to answer any questions. 

My Provider was listed in a previous directory, but not in the new directory. What does this mean?

Participating physicians, hospitals and other providers are subject to change. It is very important to verify with your provider that your Provider is still participating in our network prior to your visit. 

I confirmed that my Provider was in the EHS network, but at my next visit I was advised that they were no longer in the EHS network. What should I do?

Because participating physicians, hospitals, and other providers are subject to change, you should contact Member Services to reconfirm that your Provider is still participating in the EHS network. If your Provider is no longer participating in EHS network, you can select another in-network provider. 

Can I continue to see my provider even if he/she is no longer participating in the EHS network?

You may continue to see your non-participating Provider. However, this may affect your insurance benefits and co-pays. Please contact your insurance claim office or plan administrator for benefit information regarding out-of-network providers. 

My insurance administrator has not paid my medical claim, whom do I contact?

In the event that no payment has been made on your medical claims, you will need to contact your insurance claim office or plan administrator for more information. Their telephone number can be found on the back of your ID card. 

Do I need to use my member ID card?

In order to expedite processing, we encourage you to carry your health plan´s ID card with you at all times. Present the card whenever you receive medical services, whether from a participating or non-participating provider. The card contains important information including addresses and phone numbers necessary for claims´ payment, hospital admissions and co-payment information.

Which procedures require outpatient services?

Some surgical procedures must be performed on an outpatient basis to obtain the maximum coverage. Contact the Utilization Management/Pre-certification number listed on your ID card for information about procedures which require outpatient services. Some health plans require pre-certification of certain outpatient testing. Review the employee benefits manual supplied by your employer for specific utilization review requirements.

What must I do in case of a hospital admission?

Before an elective admission to the hospital, you or your physician must call the Utilization Management/Pre-certification number on your ID card. Advanced notice requirements vary according to benefit plans. Call your benefit administrator or your employer´s Personnel Office for information. The utilization review staff will review the treatment plan with your physician to determine medical necessity of your admission. This process is called pre-certification. If your hospital stay is not pre-certified, your plan benefits may be reduced.

 

What services require prior authorization by the Utilization Management Department?

The procedures that require pre-certification will vary by health plan. All hospital inpatient services must be authorized prior to the date of admission. Contact the Utilization Management Department as instructed on your ID Card.

What should I do if a medical emergency occurs?

In a life threatening emergency, call 911.  If you have an emergency medical problem that is not life threatening, if possible, go to the nearest participating EHS Network hospital. Pre-certification is not required prior to an emergency admission. 

Within 24 hours after an emergency admission. Call the number listed on your ID card. Contact may be made by the attending physician, a hospital representative or the patient´s family.

Will I have to file a claim?

Most EHS Network providers will automatically file your claim for you. There may be some situations where you will need to submit a claim form with corresponding documentation.