Tuality Health Alliance

FAQ and How To...

Click on the questions below for answers to Frequently Asked Questions and General How-To's.

How To...

Frequently Asked Questions

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.

How do I select a doctor?

To see which physicians and hospitals participate in the THA/OHSU 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.

How do I file a claim?

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 Payer Connection with Payer ID# THA01.

Claim Mailing address:

Select Plus Plan
PO Box 925
Hillsboro, OR 97123

If your provider bills you directly, you'll need to submit a claim form to the appropriate address for the plan you are in as shown above.

Claim forms can be found under the Forms section on this site or obtained from your human resources department.

How do I get a replacement card?

Contact Tuality Health Alliance customer service at 503-844-8104. We will be happy to provide you with replacement or additional ID cards.

How do I obtain pre-authorization for hospitalization or a surgery?

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.

What is a Preferred Provider Organization (PPO)?

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.

Can I choose a different doctor for each member of my family?

Yes. Each covered family member can select his or her own doctor.

What do I do in an emergency?

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.

Am I covered for emergency and urgent care away from home?

Yes, you're always covered wherever you are. See your plan booklet for more details.

What's "urgent" care?

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.

Do I need a referral to go to a specialist?

No. If you need to see a specialist, you're free to choose any qualified doctor, inside or outside the 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.

Your out-of-pocket costs may be lower if you see an in-network specialist.

Do I need a referral to go to the hospital?

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.

If I'm pregnant when I sign up, will I be covered?

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.