Gulf Coast Medical Management


To verify your benefits, please call WebTPA Customer Service directly at 877-697-2299.
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FAQs

What are the names of my health plan and the name of the health plan network?  The three health plans available through SMHCS are Basic, Comprehensive and Extended Plans. Basic and Comprehensive Plans utilize the Gulf Coast Select Network. The Extended Plan utilizes the Gulf Coast Provider Network.

Do I need a PCP? If you select either the Basic or Comprehensive Plans, you are required to select a PCP (Internal Medicine, Family Practice, or Pediatrician) utilizing the form available on Pulse in the Human Resources Department area. PCPs manage your care and provide referrals. If you have selected the Extended Plan you do not need to select a PCP.

Can I go to any doctor in Sarasota?  If you have selected the Comprehensive or Basic Plan, you must choose physicians in the Gulf Coast Select Network for the cost of a physician visit to be covered by your health insurance.

How do I know if a doctor I choose is in the Network? You can see all physicians in the Gulf Coast Select Network by going to gulfcoastprovider.net, click on ‘Find A Doctor’ and choose Gulf Coast Select for Comprehensive and Basic Plans or Gulf Coast Provider Network for Extended Plan members.

If I need to go to an emergency room while I am out of town, will my insurance cover the ER visit?   All emergency visits are reviewed by Gulf Coast Medical Management and, if your visit meets the criteria for a true emergency (see definition below), it will be covered by the Plan.

What is considered emergent care?  An emergency condition exists when a participant exhibits severe symptoms including severe pain, such that absence of immediate medical attention in the opinion of a lay person could reasonably be expected to result in serious jeopardy to one’s health or to a pregnancy in the case of pregnant women, serious impairment to bodily function, or serious dysfunction of any body organ or part.*

What is a Referral? Your primary care physician (PCP) may determine that you need to see a specialist for a particular ailment or health issue. This requires that the PCP refer you to the specialist by completing a referral form. You should always ask for a copy of the referral for your records and confirm that the specialist chosen by your PCP is in the provider network by going to gulfcoastprovider.net, click on ‘Find A Doctor’ and choose Gulf Coast Select

Which of my doctors is responsible for getting referrals to specialists in Network?  The Comprehensive Plan requires a referral from your Primary Care Physician after two visits to the same type of Specialist. The Basic Plan requires a referral from your Primary Care Physician for all visits to a Specialist. The Extended Plan does not require referrals.

What is an Authorization?  To assure that a procedure, service or treatment is covered by any of the three SMHCS Health Plans, you must obtain prior approval for the procedure, service or treatment.  To initiate the authorization process, the ordering physician should contact Gulf Coast Medical Management.  We encourage you to follow up with the ordering physician’s office for a status on the authorization before proceeding with the procedure, service or treatment.

Does my surgery need pre-authorization? You must obtain an authorization from Gulf Coast Medical Management before receiving the following services*:

  • Hospitalizations
  • Outpatient surgeries and invasive procedures (INCLUDING endoscopies, colonoscopies, sigmoidoscopies, bronchoscopes, EGDs, ERCP and cardiac catheterization and office procedures over $1000, except for Dermatology procedures)
  • PET scans
  • Mental health services and EAP

(*Excerpt taken from Human Resources’ Health and Wellness Summary Plan Description )

Who is responsible for getting my surgery pre-authorized?   As stated above, the ordering physician should initiate the authorization process by contacting Gulf Coast Medical Management. We encourage you to follow up with the ordering physician’s office for a status on the authorization before proceeding with the surgery.

If my specialist says I need specialty care at another facility other than Sarasota Memorial Health Care System, who is responsible for getting that authorized?   Your specialist must be in the provider network and needs to provide a letter of medical necessity, explaining why the procedure, service, or treatment cannot be performed at an SMHCS facility. The letter must also include the provider (physician) recommended, as well as the facility, which needs to be designated as a Center of Excellence for the procedure, service, or treatment requested.

The specialist should contact Gulf Coast Medical Management to begin the out-of-network pre-authorization process. The SMHCS Health Plans are physician driven and the provider should initiate the pre-authorization process and recommend the facility where the procedure, service, or treatment should be performed. The SMHCS Health Plans and Gulf Coast Medical Management cannot recommend providers and facilities outside of the established provider network.

Can I take my child for specialty care at All Children’s Hospital?  All Children’s Hospital is in the approved network but visits to All Children’s physicians and facility require a referral. Your PCP must document the need and submit a referral for such visits.

How do I know if an authorization has been approved? Call WebTPA Customer Service to see if an authorization has been approved. 

Who makes the decision on whether or not to authorize a service, treatment or procedure?  Authorization for a procedure, service, or treatment may be denied because it is determined to be either medically unnecessary or not a covered benefit. The Gulf Coast Medical Management team bases the decision to deny a request for a procedure, service, or treatment on the contents of the Summary Plan Description (SPD), which outlines covered and non-covered services, the Milliman Care Guidelines®, and the information received from your physicians. Please refer to page 81 of the SPD on the Human Resources site on the SMHCS Intranet for more details.

How can I get information on the status of a claim or verify how a claim processed?  When you or one of your dependents seeks medical or dental treatment by an in-network provider, they will submit their bill (claim) to WebTPA on your behalf or your dependent’s behalf for claims processing and will generate a payment to them when appropriate. Claims are calculated based on benefits in force at the time of service. Upon completion of your claim being processed by WebTPA, they should generate an Explanation of Benefits (EOB) to your mailing address on record. The EOB will show the provider, the date of service(s), the submitted charge(s), any contractual allowance discounted off the submitted charges, the amount that was paid and the amount you owe. If you do not receive an EOB, or if you do receive an EOB and you believe there is a discrepancy contact WebTPA Customer Service Department by calling 1-877-697-2299 or log on to their website.

How do I appeal a decision made by Gulf Coast Medical Management?  The steps to appeal a decision are outlined in the SPD, beginning on page 81, and located on the Human Resources Intranet site.

 

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