Frequently Asked Questions

What is First Health?

First Health is a national managed care organization that provides comprehensive, cost-effective managed care services for group health plans, including one of the nation’s largest PPO networks. The First Health Network is the PPO of choice for TPAs, insurance carriers and other payors looking for quality, affordable health care.

What types of services does First Health offer to insurance companies and TPAs?

In addition to the First Health Network, our portfolio of services includes flexible claims repricing and customer service options.  In addition, our value added products include Clinical Management, Non-Network Discounts and Fee Negotiations, a comprehensive Transplant Program, Dental and Vision.

Is the First Health Network national?

Yes. The First Health Network serves more than 3.5 million people across the country, with more than 550,000 participating physicians, hospitals and other health care providers in all 50 states plus the District of Columbia.

How do I find a First Health Network provider?

Currently, the most convenient way to find a doctor, hospital or other health care service provider participating in the First Health Network is by searching our online provider directory. The electronic provider directory, available 24 hours a day, 7 days a week, includes the most detailed provider information available and is constantly updated. You can also call us for assistance in locating a provider, at 1-800-226-5116.

Why should I use a First Health Network provider?

Under your group health plan, you are free to decide whether to use a First Health provider, but there are many advantages to doing so:

• They will file health insurance claims for you.
• They will collect only patient co-payments, not the full amount of the charges.
• Their services will most likely cost you less because of our contract rates with them, and in some cases, because your health plan pays higher benefits for using network providers.

Can I nominate a provider for the First Health Network?

Yes. As a member, you may ask your provider to visit us online, select the Provider link, and then select Provider Nomination under the Network Participation area to complete our online process.

How does First Health channel patients to its network?

We encourage strong benefit plans that direct or channel participants to the First Health providers within state-specific guidelines for directing care. Increasing network penetration means health care cost savings for payors and members. Our electronic directory is the most convenient way for members to locate a provider. Other channeling tools include ID cards, paycheck stuffers and early identification of high-cost members through early medical assessment.

How do providers identify a First Health member?

The “First Health” logo on your card identifies you as a First Health member.  This logo is prominently displayed on all payors ID cards to enable a provider to easily recognize the First Health Network.

Should I choose a primary care physician?

It is to your advantage to establish a close relationship with a primary care physician so that he or she can become familiar with your health care needs. However, most PPO plans do not require you to select a primary care physician.  You should verify your plan requirements with your employer or health plan administrator.

Do I need a referral to see a specialist or other provider?

Whenever additional services are required for diagnosis and treatment (e.g. specialists, laboratories, radiology facilities or hospitals), you should remind your physician that you are a First Health member and ask to be referred to another participating First Health provider. Be aware that not all providers in a single office location necessarily participate in the First Health Network. You should always confirm participation before receiving services from any provider, and verify your benefit plan with your health plan administrator.

What if I need to be admitted to a hospital or other facility for treatment?

Whenever you require admission to a hospital or behavioral health facility, many health plan administrators will require preauthorization of the admission to ensure that you receive the most appropriate services. Many services can be safely performed on an outpatient basis. To ensure that planned services are appropriate for your needs, ask your physician to call the review organization listed on your health plan card, and show your card to the admissions personnel at the facility when you are admitted.

Where do I go for emergency services?

If possible, contact your primary care physician if you require emergency services—he or she will instruct you about where to go for the most appropriate treatment.  If you are admitted to a hospital after seeking emergency treatment, you should let the admitting physician know that you are a First Health member and to contact the review organization listed on your health plan identification card within 24 hours or the first business day after being admitted.

What about behavioral health services?

Your health plan may include coverage for behavioral health services such as:

• Professional providers such as mental health counselors and psychiatrists
• Outpatient mental health facilities and psychiatric facilities/hospitals
• Chemical dependency recovery services programs

Pre-admission review is typically required for access to most behavioral health facilities. Please check your health plan to determine what it covers.

How are claims filed?

Claims will be filed by the providers.  Many options are available including our most popular method via EDI.  Refer to the specific claim filing instructions on the Member’s ID card.  Or call us at 800-226-5116 for assistance.

What are my financial responsibilities?

When you use a First Health provider for services covered under your health plan, you are responsible for paying only your deductible, co-payment (if applicable) and coinsurance. Your health plan’s explanation of benefits (EOB) should show both the billed charges and the First Health rates for services. You are not responsible for paying the difference between these amounts.

How can I obtain patient verification of benefits or eligibility?

Because we are not the claims administrator, we do not maintain benefits information or verify eligibility.  You should contact the claims administrator directly at the phone number provided on the member’s ID card.

Where can I get more information?

For answers to your questions about health benefits and eligibility, please contact your employer or health plan administrator.

If you have questions about a specific claim, contact your claims administrator.

For the most up-to-date First Health provider participation information, visit our online provider directory.

If you would like to obtain marketing materials, contact us or call us at 1-800-247-2898.  

If you need additional assistance, call First Health toll free at 1-800-226-5116. As provider participation in the First Health Network does change, you should always confirm participation prior to receiving services. You can also contact providers directly to obtain more information on the services they offer.