Frequently Asked Questions

Click on any one of the following frequently asked questions for a dropdown of the answer. If you have any additional questions about your health plan that are not addressed below, you can contact us by calling the Customer Service Center phone number at the right hand side of the screen.

Presbyterian Individual Health Plan

ID cards: You will receive your ID card in a separate mailing. Please contact our Customer Service Center if you do not receive your ID card by your effective date.

Monthly drafts and Billing: Note - For those enrolling for a January 1, 2014 effective date, payment in full must be made no later than December 15, 2013.

  • Monthly premium draft: Presbyterian Health Plan, Inc. (PHP) insurance is prepaid health coverage. This means you pay your premium payment for coverage prior to the month of coverage. If you have a monthly draft date, your prepaid monthly premium will be drafted the 25th of every month or the following business day if the 25th falls on a weekend or holiday. If we are unable to process your first month’s premium by the 25th, you will be drafted for two months of premiums on the 25th of the following month. If your draft information changes, you must inform us immediately.
  • Ongoing “bill me” payments must be received no later than the last day of the month for the next month coverage. (Payment for February must be made no later than January 31, 2014, payment for March must be made no later than February 28, 2014, etc.)

You could be terminated for non-payment of premium and only be able to apply again for insurance during the open enrollment period or special enrollment periods.

No. See question 1 for information on premium billing and the monthly premium draft.

If you feel you may have been charged incorrectly for your monthly premium, please call the Presbyterian Customer Service Center:

Phone: 505-923-5678 or 1-800-356-2219 (TTY: 1-877-298-7407)
Email: info@phs.org
Hours: Weekdays 7:00 am to 6:00 pm, Monday - Friday

myPRES is a secure online member resource center that offers you access to your medical claims history.

New to myPRES?

Make sure to have your member ID card ready. You will need to register your member ID # after you select “Manage My Health Plan”. You may also register as a patient to access MyChart and pay your bills online.

  1. Sign up by visiting www.phs.org. Select “myPRES Login.”
  2. Click on “Register for myPRES.”
  3. Follow the steps to set up your account. Have your member ID card handy.
  4. You must register as a member to access your member resources. You also may register as a patient.

Already have a myPRES account?

  1. Sign in by visiting www.phs.org.
  2. Select “myPRES Login.” Enter your user ID and password and click “Sign In.”

An individual plan is a policy that you purchase and remit premium. You are the policy owner. There is no payroll deduction through an employer or cost sharing.

  • For the health insurance marketplaces, the open enrollment period in 2013 for individual and family plans effective January 1, 2014 will last six months starting in October 1, 2013 to March 31, 2014. In subsequent years open enrollment will last from October 15 through December 7. If you buy individual and family plans outside of the exchange beginning with plans that take effect in 2014 and after, you must sign up during an open enrollment period.
  • For employer based plans open enrollment periods vary by company.

This depends on the type of plan you have. Please refer to your Presbyterian Schedule of Benefits and Subscriber Agreement, which can be found in your myPRES account under “Manage My Health Plan”. If you have a medical emergency, you should go to the nearest emergency department or call 911.

No. You can change your plan only during the annual election period, which begins on October 1. If something changes in your life (for example, marriage, the birth of a baby, etc.) you may be able to change your coverage. See the next question below.

Medical premium rates on an Individual Health Plan are based on insurance pooling. This means that individuals incurring lower claims help subsidize (pay for) individuals who have significantly more claims. Premium rate increases are determined by looking at the total claims for all the Individual plan members within all benefit options and then dividing by the total number of covered members for the recent twelve-month period. The results are the claims per member per month. The claims are then adjusted forward from the last 12 months to the renewal period to cover expected future costs.

Increases in claims costs have many causes:

  • Increases in charges for medical services
  • Increases in use of medical services
  • Aging of the population
  • Increased use of new drugs, technologies, and procedures
  • Inefficient use of services, such as the use of the emergency room when a doctor-office visit would have been effective treatment
  • You can add your spouse and/or dependent to your health plan. If the plan’s effective date is before January 1, 2014 please note that any new additions to your plan are subject to medical underwriting review and approval. To add your spouse and/or dependent, you will need the following required paperwork:
    1. Member Add Dependent Form
    2. Proof of qualifying event (e.g., birth certificate, marriage certificate, loss of coverage, etc.)
  • If your plan effective date is AFTER January 1, 2014 you can add your spouse and/or dependent by using Member Add Dependent Form if you purchased your insurance directly through Presbyterian. If you used the Health Insurance Exchange you must go to the exchange to make additions to your plan

With plans effective after January 1, 2014 a change in your life can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events include moving to a new state, a change in your income, and changes in your family size (for example, if you marry, divorce, or have a baby). An example is if you were covered under an employer plan and you lost your job. See www.healthcare.gov for details.

You can find a doctor by visiting the Presbyterian Provider Directory or by contacting the Presbyterian Customer Service Center.

Phone: 505-923-5678 or 1-800-923-6980 (TTY: 1-877-298-7407)
Email: info@phs.org
Hours:Weekdays 7:00 am to 6:00 pm, Monday - Friday

For answers to your questions about your dental plan benefits, call Delta Dental Benefit Services at (505) 855-7111 or (if outside Albuquerque) 1-877-395-9420 toll-free.

  • You must submit your termination requests in writing by using the Individual Plan Member Voluntary Termination Form[MGM1] . (If you signed up for a plan using the Health Insurance Marketplace, you will need to go there to terminate your plan.)
  • All members over the age of 18 must sign the form. Individual policies will not be automatically terminated if the member moves to another Presbyterian plan. Terminations occur only at the end of the month.
  • At the beginning of the month that you and/or your dependent(s) have a birthday, except for children until they reach age 21. Go to our Individual and Family Plan pageand scroll down to “Rate Sheet” to download our plan rate sheet that illustrates all age groups.
  • Every year, Presbyterian performs an annual renewal for Individual plan members. If your rates change, we will send you a letter informing you of the change.
  • To request to add a newborn, newly adopted child, or new guardianship of a child, send us the Add Dependent formand a copy of a document that shows proof of date of birth or a legal document such as a birth certificate. To have your child added to your plan retroactive to the date of birth, adoption, or guardianship, the document of proof must show the date of birth or the date of placement for adoption/guardianship within 61 days from the event for Individual and Family plans and 31 days for employer plans.
  • If you have purchased your plan through the health insurance marketplace, please follow the enrollment guidelines offered by the online marketplace.
  • To add a dependent on your health plan, you must submit an Add Dependent form along with qualifying event documentation (e.g., a loss of coverage document such as a certificate of creditable coverage or a marriage license).
  • On plans that are effective after January 1, 2014, follow the special enrollment guidelines on the health insurance marketplace or contact the Presbyterian Customer Service Center.

Phone: 505-923-6980 or 1-800-923-6980
Email: info@phs.org
Hours: 7:00 am to 6:00 pm, Monday – Friday

Plan information, including vision and dental resources

You can view your health plan benefit information, subscriber agreement, Schedule of Benefits, claims and deductible history, member handbook, health and wellness information, frequently asked questions and more through myPRES, your secure online member resource center. After logging in to your account, select View Health Plan Benefits under the Member Services menu.

New to myPRES? Here’s how to register:

  1. Go to www.phs.org.
  2. Select “Register now” in the myPRES Login box on the right side of the screen.
  3. Follow the simple registration process. Have your member ID card ready.

Already have a myPRES account? To log in to your secure member account:

  1. Go to www.phs.org.
  2. Enter your user name and password.

Delta Dental is the carrier for some group and individual health plans. If your plan offers dental, you can visit this website for more information on your dental coverage and in-network doctors.

Prescription Drug/Pharmacy

Most Presbyterian health plans offer prescription drug coverage. Refer to your Summary of Benefits and Coverage by logging in to myPRES to see if you have this benefit. It is you and your doctor’s responsibility to make sure that your drug is listed on the Presbyterian approved drug formulary (list). You can learn more about formularies by visiting Presbyterian’s webpage on Understanding Formularies.

  • Covered medications, both generic and brand-name, are listed in a prescription drug formulary or drug list. Most major drug classes are listed. If your prescribed medication is not on this list, you and your doctor may work together to submit a prior authorization for another type of medication that you were prescribed.
  • A prior authorization is a process between your doctor and the health plan to obtain advance approval of coverage for a prescription drug. Some prescription drugs require your doctor to provide more information about your prescription to determine coverage.
  • If you think you need a prior authorization, talk to your doctor first. He or she can initiate the prior authorization review with Presbyterian Health Plan. If you would prefer to initiate the prior authorization process yourself, you may call the Presbyterian Customer Service Center:
    Phone: 505-923-5678 or 1-800-356-2219, (TTY 1-877-298-7407)

Email: info@phs.org
Hours: 7:00 am to 6:00 pm, Monday – Friday

  • We will notify your doctor directly about the results of your prior authorization request and will notify you by mail.

Many medications can be used for multiple medical purposes, so it is important to ensure that the best drug is being used to benefit the patients’ needs. Prior authorizations allow doctors to make that determination. Drug effectiveness, drug safety, and established clinical guidelines are the baseline criteria for determining if a prior authorization will be granted.

To find out if your drug is covered through Presbyterian, you have two options:

  1. You can visit the Member Download Library to view the correct formulary list for your plan.
  2. Call the Presbyterian Customer Service Center to ask if it is covered.

Phone: 505-923-5678 or 1-800-356-2219, (TTY 1-877-298-7407)

Email: info@phs.org
Hours: 7:00 am to 6:00 pm, Monday – Friday

If your drug is not listed on your copy of the Presbyterian formulary, you may contact the Presbyterian Customer Service Center to be sure it isn’t covered.

Phone: 505-923-5678 or 1-800-356-2219, (TTY 1-877-298-7407)

Email: info@phs.org
Hours: 7:00 am to 6:00 pm, Monday – Friday

If the Presbyterian Customer Service Center confirms that we don’t cover your drug

You or your doctor may ask us to make a pharmacy exception. This means asking Presbyterian to cover your drug or waive limits on your drug. If we agree to make an exception, you may have more out-of-pocket costs. To learn more about your plan’s drug coverage or to initiate a pharmacy exception request, please contact the Presbyterian Customer Service Center.
Phone: 505-923-5678 or 1-800-356-2219, (TTY 1-877-298-7407)

Email: info@phs.org
Hours: 7:00 am to 6:00 pm, Monday – Friday

  • Tip 1: Read your Presbyterian formulary by going to the Member Download Library. If your drug is not listed on the drug list, talk to your doctor to see if your medication can be substituted. It could save you money.

Note: Depending on your health plan type, you will also want to learn about your prescription benefits and cost-sharing information and how it applies to prescription drugs. This will help ensure that you are not caught off guard when it comes time to fill a prescription.

  • Tip 2: Consider generic drugs. Generic drugs are regulated by the U.S. Food and Drug Administration (FDA) and have the same active drug ingredients, safety, performance, quality, and strengths as brand name drugs. Talk to your doctor or pharmacist if a generic equivalent is available for you. You can learn more about generic drugs by visiting the FDA Generic Drugs Questions and Answers web page.
  • Tip 3: Take advantage of Rx Home Delivery. Your prescription benefit includes the use of Walgreens Prescription Mail Service. Choosing mail service allows you to enjoy delivery of your maintenance medications to the location of your choice—it’s easy, convenient, and can save you time and money. The benefits of mail service include:
    • Easy registration and ordering
    • Quick delivery of medications in confidential, tamper-evident packaging
    • Free standard shipping
    • Important medication information included with every order
    • Access to a clinical pharmacist 24/7
    • Auto-refill option
    • Online account management and support
    • Lower cost-sharing for some members
    • The Walgreens Customer Care Center offers:
      • Order, billing, and shipping assistance
      • Technology for the hearing-impaired
      • Over-the-phone translation services in more than 150 languages
      • Medicare members may view the Walgreens Mail Service Pharmacy brochure here.

Learning how much a drug will cost and searching for less expensive alternatives ahead of time can save you money. You can log in to your myPRES account and select Manage My Prescriptions, which allows you to:

  • Check your prescription benefits and copayment
  • Register for mail-order prescription delivery via Walgreens Mail Service
  • Find pharmacies in your area
  • Find out about your medications and possible side effects
  • Check your medication history
  • Access the Member Reimbursement Form
  • Learn about drug-to-drug interactions
  • Get information what to do if your medication is not covered
  • Email: AskRx@phs.org
  • Customer service: 505-923-5678
  • Outside the Albuquerque area: 1-800-356-2219
  • TTY: 1-877-298-7407

Claims

There are many reasons why a claim could be denied. Common reasons include a provider submitting insufficient information needed to process the claim, or visiting an out-of-network provider without first obtaining a prior authorization. If you have any questions about the denial of a claim, please call the Presbyterian Customer Service Center using the phone number located on the back of your Presbyterian ID card or at info@phs.org.

When you receive care from a provider, the provider submits a medical claim form to Presbyterian Health Plan for reimbursement. The medical claim contains details of the services provided including the charge amounts for each of the services. Presbyterian Health Plan will process the claim according to your health insurance benefits and regulatory guidelines. An EOB is generated after the claim has been processed and provides a record of the services processed according to your health insurance. An EOB displays the following information:

  • Service Dates: Identifies the date of service.
  • Services Provided: A description of the medical service.
  • Amount Billed: The amount the provider charged for the service.
  • Amount Allowed: The amount Presbyterian Health Plan allowed for the service.
  • Copayment or Coinsurance: The copay and/or coinsurance amount you are financially responsible for.
  • Deductible: The deductible amount you are financially responsible for.
  • Amount Paid by Plan: The amount Presbyterian Health Plan reimbursed the provider.
  • You May Be Billed: The amount you are financially responsible for.
  • Codes: The explanation codes provide detail about how the claim was processed according to your plan coverage. A description of the codes is located under the Code Message Description section of the EOB.

You can log in to myPRES to access your claim information. Select the claim in question and you will see an explanation for each code at the bottom of the page.

An adjustment may be performed when Presbyterian Health Plan determines that a claim was processed incorrectly or when a provider submits a corrected claim. Depending on the corrections, Presbyterian Health Plan may pay more money on a claim or recover amounts that have been overpaid. Contact the Presbyterian Customer Service Center if you have questions about why an adjustment was made on a claim and if you may have a financial responsibility.

Subrogation is a process in which a health insurance company can seek recovery from a third party legally responsible for a medical accident or injury after the health insurance has processed the services.

Health insurance companies can subrogate if they have paid your medical costs and you later recover amounts for the medical costs in a lawsuit. If Presbyterian Health Plan has paid for medical services related to the lawsuit, you will receive documents that will detail the amount your insurance company has paid for your injury claim and an explanation of the insurance company’s subrogation rights to collect.

When you receive medical treatment from an in-network provider, the provider will submit the claim to Presbyterian Health Plan for payment. Depending upon the service, you may be responsible for a copayment at the time of the visit. After Presbyterian Health Plan has processed the claim, you may owe the provider any coinsurance and/or deductible amounts according to your benefit plan. Refer to your benefit plan for a summary of copays, coinsurance and deductible amounts.

When you visit an out-of-network provider, the provider may require payment in full at the time of service and require that you send the claim to Presbyterian Health Plan. Please be aware that non-urgent or non-emergent services received from an out-of-network provider may require prior authorization from Presbyterian Health Plan. To submit a claim to Presbyterian Health Plan, please complete a Member Medical and Pharmacy Claim Form and submit the information to:

Presbyterian Health Plan – for employer group members
P.O. Box 27489
Albuquerque, NM 87125-7489

Presbyterian Insurance Company – for Individual plan members
P.O. Box 26267
Albuquerque, NM 87125-6267

If you feel you may have been charged incorrectly for medical services, here are some steps you can take.

  • Call the Presbyterian Customer Service Center or the facility where your services were rendered to inquire about the charges. If you are disputing an incorrect claim, you can request a complete copy of all medical services you were billed for. You can also request an inquiry to be made into the claim.
  • Collect any documentation related to the charges.
  • Once you receive the results of the inquiry, if you are not satisfied with the results, you can request a meeting with Presbyterian Health Plan to discuss the inconsistency.
  • If you were working to have a service covered when the coverage was denied, you will need to talk to both the doctor and Presbyterian Health Plan. The cause for the denial could be as simple as encoding error and may be able to be corrected quickly.

Tips:

  • Make sure that all procedures that require pre-authorization have received authorization to avoid any billing issues. Generally, the doctor will take care of this, but you can double check before the procedure by contacting the Presbyterian Customer Service Center at the number on the back of your ID card.
  • Sometimes a hospital is on the Presbyterian in-network list, but some of its doctors may not be. Be sure to ask about this to ensure you are staying in-network for all your medical services.

A reasonable (or usual) and customary fee is the amount that your health plan determines is the normal range of payment for a specific health-related service or medical procedure within a given geographic area. Some examples may include the following:

  • Presbyterian Health Plan’s fee schedule for the services provided.
  • Fees that a professional provider usually charges for a given service.
  • Fees that fall within the range of usual charges for a given service filed by most professional providers in the same locality who have similar training and experience.
  • Fees that are usual and customary or that could not be considered excessive in a particular case because of unusual circumstances.

Refer to your plan documents for a full description. Some deductible plans cover 100% after the deductible is met including copays and coinsurance. Other plans still require the copay and coinsurance after the deductible is met. Also, some benefits could have maximums or limits. This means that if you have met your maximum lifetime benefits, you will be responsible for any remaining payments.

It may be that you haven’t met your deductibles for both plans. If this is the case, you may still owe your cost-sharing amounts (deductible, copayment, coinsurance).

You have the right to make a complaint if you have concerns or problems about your coverage or care. Appeals and grievances are the two different types of complaints you can make.

  • An appeal is the type of complaint you make when you want us to reconsider a decision we have made about what services are covered for you or what we will pay.
  • A grievance is the type of complaint you make if you have any other type of problem with Presbyterian or one of our plan providers.
  • You can submit a complaint by calling Presbyterian Customer Service Center or by submitting a complaint online.

Enrollment, What to Expect After

Please click here for Individual Health Plan information.

If you are a member of an Employer Group Plan, there are a few things you can expect from Presbyterian after enrollment:

  • You will receive your ID card, Group Subscriber Agreement and Schedule of Benefits prior to your group’s plan effective date or approximately 30 days after you have completed the enrollment process with your employer.
  • If your employer has enrolled for the Presbyterian Welcome On-Boarding Program, you will receive a series of welcome emails that will help you make the most of your health plan benefits and instructions to take advantage of the tools and resources available to you.
  • Please inform us if you have additional healthcare coverage. By sharing this information we can better coordinate your benefits. You can do this by contacting Presbyterian Customer Service and request a Coordination of Benefits form.
  • Transition of Care: Please let us know if you were previously covered by another insurance company and you have a pre-existing medical condition or pharmacy drug prescription. We will assist you in the transition to ensure that your benefits are handled properly.
  • If you are currently seeing a primary care provider (PCP) or specialist through another network, under some circumstances you may continue to do so. In these instances, you must let us know so we can help you temporarily continue certain treatments with providers outside of the network following enrollment. This is called transition of care.
  • Transition of care coverage may include upcoming surgeries, prenatal care, specialist visits, home healthcare, durable medical equipment and other types of services. You will need to fill out the Transition of Care Services Request form online or request one from the Presbyterian Customer Service Center.
  • Presbyterian Health Plan’s Health Services department will review your request to determine if it meets the criteria for transition of care coverage. Upon approval, you will be given a prior authorization for any eligible coverage. You might find it helpful to watch this video on prior authorizations.
  • If you currently receive case management or disease management services through another plan, you may also be able to enroll in Presbyterian’s case management and disease management programs.

Services that are pre-approved through transition of care by Presbyterian Health Services are covered at your plan’s in-network benefit level through the specified coverage period. There may be some services – such as outpatient surgery, lab work, radiology and durable medical equipment – that will require a transition to another facility. We will provide you a listing of those facilities in the Presbyterian network. For pregnancies, the coverage period may be longer. Please indicate on the Transition of Care form if you are pregnant.

Dependent Coverage for employer group plans

If you or a covered family member needs medical services outside of New Mexico, you can access the MultiPlan/PHCS network to begin your search for a doctor or facility. Here are some things to keep in mind about the MultiPlan/PHCS network:

  • The Multiplan/PHCS network applies only outside of New Mexico.
  • PPO members have access to a nationwide network of providers with in-network benefits through the Multiplan/PHCS.
  • For HMO members, the Multiplan/PHCS network is only for emergent or urgent care outside of New Mexico, unless otherwise pre-authorized.
  • In-network benefits will not apply for Presbyterian’s Individual Care, PPO Conversion, NM Healthcare Alliance, Point of Sale (POS) members and certain Administrative Services Only (ASO) Plans.

You should contact your employer’s human resources department for specific instructions and an enrollment form to add your newborn to your health plan. An eligible newborn is covered for 31 days past their date of birth. In order to continue healthcare coverage after this date, the newborn must be enrolled within 31 days of birth or adoption.

If you are a Presbyterian member when your spouse loses their group coverage, he or she can enroll as your dependent. This will only be accepted if the enrollment occurs within 31 days of the date that the coverage ended under the former group health plan coverage. You will need to provide us with a Certificate of Creditable Coverage, which your spouse can get from his or her former employer.

If you are a new employee of an organization, you may add a spouse and/or dependents within a certain timeframe of your employment in order to receive guaranteed acceptance into the plans. Check with your employer for specific timeframes. You can also make a change if you experience any qualifying life event. Examples of a qualifying life event include:

  • Birth
  • Adoption
  • Change in marital status
  • Death of spouse or dependent
  • Change in spouse employment status

It is your responsibility to communicate the qualifying life event to Presbyterian Health Plan within 30 days of when the event occurred. You must provide supporting documentation of dependent status (e.g., marriage certificate, birth certificate, etc.); otherwise, you will be allowed to add a dependent only during your company’s annual open enrollment period.

Member ID Card

When you need care but don’t yet have your ID card, there are a few things you can do:

  • Your provider’s office should be able to access your health plan information with your social security number.
  • Call the Presbyterian Customer Service Center:

Phone: 505-923-5678 or 1-800-356-2219; TTY 1-877-298-7407
Email:
info@phs.org
Hours: 7:00 am to 6:00 pm, Monday – Friday

  • Log in to your myPRES account and select Manage My Health Plan, then Request ID card, to view and print a temporary ID card.

Log in to your myPRES account and select Manage My Health Plan, then Request ID card, to view and print a temporary ID card.

Note: If you need to order an ID card for a member on your health plan, you will need to access that member’s specific myPRES account. Each Presbyterian health plan member requires his or her own separate account with his or her own user name and password. Accounts are not joined.

Preventive Benefits

We know preventive care is important to you and your family. Many preventive services are covered at 100 percent and don’t require cost-sharing (copayments or deductible). Your doctor must bill claims with preventive codes for services to be covered as preventive. Any further testing or treatment identified during a preventive service means regular copays, coinsurance, or deductibles may apply. The following list does not contain all the preventive services covered by your plan. It is very important to see your Subscriber Agreement for the whole list, details, and restrictions.

  • Routine physical exams
  • Well-child care, including vision and hearing screening (through age 26)
  • Routine immunizations
  • Preventive Services for Women
  • Colonoscopy
  • Health education - to discuss lifestyle behaviors that promote health and well-being
  • Breastfeeding support, supplies and counseling (for one year after delivery)
  • Pap smear
  • Human papilloma virus (HPV) vaccine for females
  • Mammography
  • A preventive service refers to services that help you stay healthy and identify health concerns early. These can be defined as an annual routine check-up with your provider, such as an annual physical, breast screening, prostate screening or blood pressure check. If you get a service or test listed in the Preventive Care Guidelines Presbyterian will pay 100 percent whether you have met your deductible or not.
  • A diagnostic service is prompted when you already have signs of a health problem, such as a cough, trouble breathing, or body pain. A diagnostic service can be identified if you go in for a preventive service and the doctor finds something abnormal as a result of that service that may need further determination. If this is the case, a portion of your services deemed preventive will be covered except for the service deemed diagnostic. You will be billed for the diagnostic service up to the amount of your deductible, if applicable. You may also be responsible for any coinsurance, depending on your plan.

How often you should go to the doctor? What check-ups, tests and screenings should you have? Your healthcare provider is the best source to answer questions about your health. However, Presbyterian offers Preventive Health Guidelines for Healthy Children and Adults to give you an overview of what preventive services you need to stay healthy. Presbyterian has developed these guidelines for healthy children and adults in accordance with national standards of preventive medicine.

Emergency & Urgent Care

An Emergency Room should be reserved for serious conditions. Do not take chances with anything that could be life-threatening. Below is a list of critical conditions where the Emergency Room is the best place for treatment.

  • Stroke
  • Heart attack
  • Severe bleeding
  • Head injury
  • Chest pain
  • Difficulty breathing
  • Severe bleeding or head trauma
  • Loss of consciousness
  • Sudden loss of vision or blurred vision

Your primary care provider’s (PCP) office or an Urgent Care center should be reserved for less-critical conditions that are not life-threatening. Below is a brief list of these conditions where your PCP’s office or an Urgent Care facility is the best place for treatment.

  • Allergic reactions (non-life-threatening)
  • Fever or flu-like symptoms
  • Rash or other skin irritations
  • Minor burns or injuries
  • Ear infections
  • Mild asthma
  • Sprains and strains
  • Coughs, colds and sore throats
  • Animal bites
  • Broken bones

But if you think it’s a medical emergency, don’t wait – call 911.

  • Presbyterian offers the NurseAdviceSM New Mexico line 24 hours a day, seven days a week. When you call the NurseAdvice New Mexico line (1-866-221-9679), you will speak to a registered nurse who can help you decide where to get the right treatment for your medical condition including self-care measures you can take home.
  • You may also call your primary care provider’s (PCP) office. After hours, the PCP will leave a number for you to call.

Find a Doctor - Provider Networks

You can search our Find a Doctor Quick Search database to locate a provider in the Presbyterian Health Plan system.

  • A PCP is the healthcare provider who provides or coordinates most of your care. If you need a specialist, your PCP keeps in contact with your specialist to ensure continuity of care. PCPs are doctors and other types of providers – e.g., nurse practitioners – who specialize in general and family practice, internal medicine, and pediatrics.
  • If your plan requires you to pick a PCP, his or her name will be listed on your member ID card.

Selecting your PCP is a personal choice. It’s important that you select a PCP who best suits you and your family’s needs. If you are unable to select a PCP at the time you enroll in your health plan, use our online Find a Doctor tool to find a PCP. You may also call the Presbyterian Customer Service Center for help with selecting one for you. You can reach our Customer Service at:

Phone: 505-923-5678 or 1-800-356-2219; TTY 1-877-298-7407
Email:
info@phs.org
Hours: 7:00 am to 6:00 pm, Monday – Friday

Yes. If you have dependents or a spouse covered under your Presbyterian Health Plan, you can select a different PCP in the same Presbyterian Plan network.

Yes. You can call the Presbyterian Customer Service Center for help selecting a new PCP over the telephone.

Phone: 505-923-5678 or 1-800-356-2219; TTY 1-877-298-7407
Email:
info@phs.org
Hours: 7:00 am to 6:00 pm, Monday – Friday

Most of the time, your PCP will make a recommendation for a specialist depending on the type of care you will need. However, you and your doctor can work together to decide the best course of action to take. In some cases, you may be able to see a specialist directly without a referral from your PCP.

Coverage Outside New Mexico

To avoid any possible restrictions for medical services rendered by out-of-network facilities or doctors when outside of the New Mexico area, Presbyterian offers MultiPlan/PHCS network for some plan members. (See your Subscriber Agreement.) MultiPlan has close to 900,000 healthcare providers under contract that may be considered in-network for your plan.

  • If you have a logo for the MultiPlan/PHCShealthcare provider network on the back of your member ID card, you can receive medical care while traveling outside of New Mexico without paying out-of-network costs. The Multiplan/PHCS network has more than 900,000 providers and over 4,000 facilities that can provide care at preferred rates. Remember to present your insurance ID card every time you seek medical treatment.

  • Please note:
    • The Multiplan/PHCS network applies only outside of New Mexico.
    • PPO members have access to a nationwide network of providers with in-network benefits through the Multiplan/PHCS.
    • For HMO members, the Multiplan/PHCS network is only for emergent or urgent care outside of New Mexico, unless otherwise pre-authorized.
    • In-network benefits will not apply for Presbyterian’s Individual Care, PPO Conversion, NM Healthcare Alliance, Point of Sale (POS) members and certain Administrative Services Only (ASO) Plans.

In case of an emergency, go to the nearest emergency department or call 911

Healthcare Reform & You

The Affordable Care Act was signed into law on March 23, 2010. It is a wide-ranging federal law that includes insurance, payment and delivery reform. Some of provisions include:

  • Guaranteed access to health coverage and a mandate that all Americans buy (or have) health insurance.
  • Consumer protections that eliminate denials of coverage based on pre-existing conditions, and the elimination of dollar limitations on benefits.
  • Premium and benefit subsidies for consumers based on income to help afford insurance.
  • Expansion of Medicaid eligibility in New Mexico (called Centennial Care).
  • The New Mexico Health Insurance Exchange is a marketplace used to find out if you qualify for premium and benefit subsidies to help afford insurance or tell if you are eligible for Medicaid. Individuals and employers can compare healthcare plans among different carriers and purchase the plan that best suits their needs.
  • The exchange will begin enrolling people on October 1, 2013, and coverage will be effective January 1, 2014.
  • Five different plan levels will be available. Four of the levels will be named Bronze, Silver, Gold and Platinum. The fifth plan, catastrophic, is described below.
  • The Bronze plan generally offers the lowest premium in exchange for the highest out-of-pocket costs. The Silver level is for individuals who want financial help with out-of-pocket costs such as copayments and deductibles. Under the Gold and Platinum levels, premiums will be higher, but member cost-sharing will be lower.
  • The fifth level, a catastrophic plan, is available for people younger than 30 and those suffering financial hardship.
  • Plan rates will range depending on plan benefits and age, geographic location and tobacco use.

Plan rates will also be lower than listed for many people earning less than $46,000 a year (in 2013), because they will qualify for subsidies (financial help) to make insurance more affordable. The subsidies will be offered on a sliding scale, meaning that people with lower incomes can get larger subsidies.

  • Presbyterian Health Plan will be offering approximately 36 different health plans for individuals and small groups through the New Mexico Health Insurance Exchange and outside the Exchange. This allows us to offer a variety of deductible options to consumers.
  • Presbyterian is helping our current members and the many uninsured that we serve to find the health coverage that will best serve their needs through face-to-face outreach and online options.
  • As the only private, not-for-profit healthcare system in New Mexico, Presbyterian supports healthcare reform initiatives that provide greater access to health insurance and healthcare.
  • Use the Coverage Connector tool on www.phs.org to help determine if you may receive a subsidy for an individual plan or apply for Medicaid.

If you receive your health plan benefits through your work, your employer decides which plans to offer their employees. Your employer may choose to keep the same health plan that was in place when the Affordable Care Act became law, or there may be other health plans offered that better fit your company’s healthcare needs. In any case, if your health plan changes at renewal, you will receive information about your new health plan from Presbyterian.

The Affordable Care Act requires that health plans cover “essential health benefits.”

The Affordable Care Act defines essential health benefits on Healthcare.gov as the following:

  • Hospitalization
  • Maternity and newborn care
  • Prescription drugs
  • Laboratory services
  • Emergency services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care
  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Rehabilitative services and devices

Presbyterian will continue to cover all preventive health services required by the Affordable Care Act. These services may include well-baby and well-child visits, annual adult physicals and routine gynecological exams. If your employer decides to keep the same benefit plan that was in place when the Affordable Care Act became law in 2010, some cost-sharing for preventive health services may still apply. You can check your current benefit plan and copayments at any time by logging in to your myPRES account.

Contact Us

Offices for Presbyterian Healthcare Administration and Business Services, Presbyterian Health Plan, Inc. and Presbyterian Insurance Company, Inc. are located in a central area near the Albuquerque Sunport airport.

Presbyterian Administrative Center (PAC) and Business Office

Street address: 2501 Buena Vista SE, Albuquerque, 87106

Phone: (505) 923-5700

Mailing address: P.O. Box 26666, Albuquerque, 87125-6666

Presbyterian Health Plan/Presbyterian Insurance Co.
1-866-388-7737 (PRES)

Presbyterian Health Plan Commercial (HMO, POS)/ASO (Administrative Service Only):
Phone: (505) 923-5678 or 1-800-356-2219; TTY: 1-877-298-7407
Hours: 7:00 a.m. to 6:00 p.m., Monday-Friday
Mailing address: P.O. Box 27489, Albuquerque, NM 87125

Presbyterian Insurance Company Commercial (PPO):
Phone: (505) 923-6980 or 1-800-923-6980; TTY: 1-877-298-7407
Hours: 7:00 a.m. to 6:00 p.m., Monday-Friday
Mailing address: P.O. Box 26267, Albuquerque, NM 87125-6267

For a full list of contact information, visit the Presbyterian Contact Us web page.

TOPIC: Know Your Health Plan Benefits

Presbyterian offers a collection of educational videos to help you better understand your Presbyterian health plan benefits and available resources.

TOPIC: Helpful Links for Members