FAQ and How To...
Click on the questions below for answers to Frequently Asked Questions and General How-To's.
- How do I select a doctor?
- How do I file a claim?
- How do I get a replacement card?
- How do I obtain a precertification for hospitalization or a surgery?
Frequently Asked Questions
- What is a Preferred Provider Organization (PPO)?
- Can I choose a different doctor for each member of my family?
- What do I do in an emergency?
- Am I covered for emergency and urgent care away from home?
- What's "urgent" care?
- Do I need a referral to go to a specialist?
- Do I need a referral to go to a hospital?
- If I'm pregnant when I sign up, will I be covered?
All information provided on this web site is in summary and intended to provide highlights of your plans. We strongly recommend referring to the Plan booklet for complete details before making any decisions related to your eligibility, benefits and coverage.
To see which physicians and hospitals participate in the THA/HRNW or First Choice Health Network, search their online provider directories or call them at the number listed in the Contacts page of this site.
If you are enrolled in the Choice PPO plan, you may select a network or non-network doctor, but remember that using a participating doctor could save you money. See Plan Overviews or Benefit Booklets for details.
If you are enrolled in the My Extended Network plan, you may select a First Choice Health Network doctor, but remember that using a preferred THA/HRNW doctor could save you money. See Tuality Healthcare Plan Booklet for details
When you receive care, your doctor's office usually takes care of filing your claim. However, to ensure your claim is sent to the proper address you must show your doctor's receptionist or billing department your ID card. It is important that you ask that they update their computer records with the claim address information shown on the back of the card.
Your provider may submit your claim electronically through the following venders:
- Payer Connection – Payer ID # THASC
- Relay Health – Payer ID # THA2012
- Change Healthcare – Payer ID # 93112
Claim Mailing address:
Tuality Health Alliance
PO Box 925
Hillsboro, OR 97123
If your provider bills you directly, you'll need to submit the following information:
- Name and tax identification number for provider of service
- Date services were rendered
- Detailed invoice of services rendered that includes ICD-10 diagnosis codes and CPT procedure codes
- Billed charges for each service
- Receipt showing services have been paid in full
Member reimbursement claims must still adhere to guidelines and are subject to eligible benefits of the plans.
Contact Tuality Health Alliance customer service at 503-844-8104. We will be happy to provide you with replacement or additional ID cards.
Prior to a planned hospital admission or surgery, you or your doctor must call Innovative Care Management to request "pre-admission certification". Pre-admission certification is required to make sure you'll receive the maximum amount of benefits under your plan. Failure to call could result in a penalty or reduced benefit for your hospital admission and/or surgery.
A Preferred Provider Organization (PPO) is a network of health care providers that deliver their services at negotiated "preferred" rates. When care is received from a PPO provider, there are generally higher benefits coverage, lower out-of-pocket expenses, and no claim forms.
The Tuality Select Plan uses two different PPO networks – THA/OHSU and First Choice Health.
Yes. Each covered family member can select his or her own doctor.
Seek qualified help immediately. You and your family members are covered for emergency medical services anywhere, 24 hours a day.
An emergency is a sudden and unexpected onset of an injury or serious illness that, if not treated immediately, may result in serious medical complications, loss of life or permanent impairment of bodily functions. Some examples include (but are not limited to) chest pains, loss of consciousness, excessive bleeding, broken bones, loss of breathing or convulsions.
In an emergency, call for emergency assistance or go to the nearest hospital emergency room immediately. You, your family or your doctor must call Innovative Care Management within 24 hours in the event of an admission to a hospital.
Yes, you're always covered wherever you are. See your plan booklet for more details.
When prompt medical attention is needed in a non-emergency situation, that's called "urgent" care.
Examples of urgent care needs include ear infections, sprains, high fevers, vomiting and urinary tract infections. Call your regular doctor if you're able. If you or a covered family member experience a severe medical condition and time is critical or you're away from home, seek care at the closest facility. Or contact Tuality Health Alliance or First Choice Health for help in locating the closest participating provider. If the urgent care provider participates in the PPO, you'll have the advantage of in-network benefits levels for your covered services. Be aware that urgent situations are not considered to be emergencies.
No. If you need to see a specialist, you're free to choose any qualified doctor inside your PPO network. You're always covered. Although referrals are never required, the doctor providing your primary care can probably make some helpful suggestions as to which type of specialist you should see.
If you are on the My Extended Plan, your out-of-pocket costs may be lower if you see a preferred THA/HRNW specialist.
No. You're free to use any hospital you wish for inpatient or outpatient care. However, your costs will be lower if you go to a hospital affiliated with the PPO network.
Prior to a planned hospital admission, you or your doctor must call Innovative Care Management to request "pre-admission certification". Pre-admission certification is required to make sure you'll receive the maximum amount of benefits under your plan. Failure to call could result in a penalty or reduced benefit for your hospital admission.
Your prenatal care services incurred from the date you become eligible in the plan will be covered according to the terms of your medical plan. You should review your Plan Booklet for the details of your coverage.