We routinely determine PPO coverage by applying a 20-mile radius/30-minute drive time to an acute care hospital from the employee’s home ZIP code. However, we are also able to adjust the mileage radius used at your request. PPO coverage is then further broken down into two categories:

• Covered – This category identifies those employees within the given service parameters of a provider system who have routine access to an acute care hospital.
• Not Covered – This category includes those employees that reside in areas where there are no Preferred Providers or reside too far from a provider system to avail themselves of a preferred provider.

A wide spectrum of providers, specialists and medical providers participate, including, but not limited to:

Please note, however, that the number and types of providers will vary from provider system to provider system.

The identification of members enrolled in the PPO is determined by the plan participant/insured Benefit I.D. Card. The I.D. card will include all appropriate benefit information, including the AHA logo and, in some instances, the local provider system's logo.

In numerous instances, the participating hospitals are affiliated with such facilities, as well as additional types of service providers.

The majority of participating hospitals offer per-diem rates. In certain cases, if a claim reaches a certain dollar amount, the claim reverts to a specified percent off the billed charges.

The majority of participating hospitals offer a discount method of reimbursement for outpatient services.

Reimbursement rates for hospitals, physicians and other providers are set for one-year periods, in accordance with the provider’s fiscal or calendar year or in accordance with their PPO contractual agreement. There are, however, provisions for the increase of particular rates if unforeseen market or industry factors require it.

The majority of participating provider systems have established a Maximum Allowable Payable (MAP) fee schedule that covers all participating physicians in their service area. Other types of fee arrangements include discounts from charges, DRGs or per-diems.

Yes. There must be at least a 10-20% co-insurance differential. Certain participating AHA PPOs require greater co-insurance differentials and additional incentives. We encourage participating plans to implement several plan design changes in order to increase the utilization of preferred providers and maximize the potential savings.

Yes. Timely payment is one of the several incentives for a provider to enter into a preferred provider arrangement. Each of the provider systems include specific language in their contracts pertaining to preferred time payments for preferred patients. If payment is not made on a timely basis as set forth in the AHA agreement, preferred rates and fees will be forfeited. In the event that payment is delayed due to coordination of benefits or other reasons, the preferred provider must be notified of the reason for the delay within the preferred time frames for payment.

Yes. Each of the participating provider systems will provide the names of contact personnel responsible for provider relations and dispute resolution. AHA will also provide assistance in answering questions or helping to resolve disputes a client or provider system may have.

The first step is to ask the provider to contact us. We will then follow up with the provider system. Please note that providers may not always be able to participate.

Fees quoted apply to the AHA provider system(s) that would be serving the client’s employees and dependents in their specific service areas. In the event that a member seeks services in another state, and that facility or provider participates in the AHA-USA Reciprocity Program, the fee for access to that particular facility or provider would be based on the percentage of savings.

We do not contract with any other national PPO networks. However, we will contract with national providers in the following areas: Pharmacy, vision, dental, durable medical equipment and home health.

The following Access Fee Methodologies have been accepted by the participating provider systems:

• Per Employee/Per Month
• Percentage of Savings

The most commonly used PPO Access Fee is Per Employee/Per Month

When Per Employee/Per Month is used, and more than one provider system is required, we provide you with a composite rate, which is a combined rate based on the number of employees in each provider system that is going to be accessed.
If Percentage of Savings is used, the savings are determined by calculating the difference between the Gross Billed Charge and PPO Allowable (Preferred) Fee. The agreed-upon percentage is calculated from this figure (the savings).

Both of the above payment methodologies are affected by the types and number of services the client requests AHA to perform.

In order to meet this need, we have established the AHA-USA Reciprocity Program. In the event a member seeks service when they are traveling, preferred rates will apply as long as the facility or provider belongs to a provider system which participates in the AHA-USA Reciprocity Program. The cost for this service is based upon one of the most cost-effective Percentage of Savings arrangements in the marketplace.

An advantage we have over most other national networks is that the participating hospitals and physicians own the majority of PPOs participating in AHA, which helps lower costs. In addition, our Alliance members are generally the leaders in their community with respect to the number of providers and the number of lives they serve, which results in more aggressive reductions.

Overall hospital savings range from 5% to more than 60%, depending on the services a hospital offers, the geographic location of the hospital and the efficiency of the hospital. Physician savings range from 10% to more than 50%, depending on the geographic location of the provider or facility.

While we firmly believe that the level of savings attainable in the Alliance are significant, there are a number of factors affecting the level of savings a client may expect or experience. When comparing networks, it is important to note that, while we maintain a significant presence in large metropolitan areas, we also serve a considerable number of rural communities.

Yes, ONE

In most cases we perform the claims repricing. As a result of our state-of-the-art claims repricing system, we have been able to achieve turnaround times on clean claims that exceed industry standards.

Yes. We are HIPAA compliant with respect to the ASC X12N 837 (005010) Transaction Sets, and we are certified by ClarEDI.

No. We have partnered and contracted with local, regional and national PPOs from around the US to bring to market a comprehesive PPO solution