NetCare provides member identification cards for employees and dependents enrolled in the Plan. The Member Identification Card indicates the following:

• Member’s Name
• Employer Group Name
• United HealthCare ID Number (applicable for U.S. Mainland Care)
• NetCare Identification Number
• Optum Rx BIN Number

The back side of the card has contact information and claims submittal instructions that enables medical providers to obtain eligibility and benefit coverage information such as co-payments and co-insurance and benefit limitations.

Your member identification card must be presented to the provider at the time of service. To replace a lost or stolen card, please contact our Customer Service Department at 472-3610 or log onto our website at www.netcarelifeandhealth.com to make an express request for a replacement card. There will be a $2.00 charge for each replacement card. The replacement fee will be charged even if the member is not responsible for the lost or stolen card.

As a NetCare member, you have the right to:

• Receive information regarding the Plan including services, benefits, and limitations.
• Information on your rights and responsibilities and any charges you may be responsible for.
• Obtain evidence of medical credential of a Plan Provider.
• Receive courteous and personal attention and be treated with respect and dignity. NetCare personnel, network doctors, other health care professionals and their staff will respect your privacy.
• Privacy and confidentiality of your medical history, enrollment file and any Protected Health Information (PHI).
• Voice concerns about the service and care received.
• File a grievance for an administrative or medical complaint and hearing procedures without retribution from the Health Plan.
• Have coverage denials reviewed by appropriate medical professionals consistent with NetCare’s review procedures. Informal and formal steps are available to you to resolve all complaints/grievances/appeals.
• Choose a primary care physician which enables you to participate in the management of your total health care needs, including the right to refuse care from a specific practitioner.
• Change Primary Care Physician (PCP) if so desired. Limited to one request for change per day.
• Receive information from health care professionals about your medications, including what are the medications, how to take them, and possible side effects.
• Openly discuss with your doctor the appropriate and medically necessary treatment options for your condition, regardless of cost or benefit coverage.
• Be informed if a health care professional plans to use an experimental treatment or procedure in your care. You have the right to refuse to participate in research projects.
• Complete an Advance Directive, Living Will or other directive and give it to your health care professionals.
• Receive urgently needed medically necessary care.
• Privacy and confidentiality regarding your medical care and records. The Health Plan will not release personal health information to an employer, or its designee without a signed Authorization for the Use or Disclosure of Protected Health Information by you. Reference Notice of Privacy Practices for a description of how NetCare Health protects your personal health information).
• Access to doctors, health care professionals and other health care facilities.
• Participate in decisions about your care with your doctor and other health care professionals.
• Receive information about NetCare Health, our services, and provider network.

As a NetCare member, you have the responsibility to:

• Know your benefit coverage and its limitations.
• Contact an appropriate health care professional when you have a medical need or concern.
• Show your health plan member ID card before receiving health care services.
• Never authorize anyone else to use your ID card.
• Use emergency room services only for injury and illness that, in the judgment of a reasonable person, requires immediate treatment to avoid jeopardy to life or health.
• Provide complete and accurate information to the providers rendering care.
• Follow agreed-upon instructions and guidelines of doctors and health care professionals.
• Participate in understanding your health problems and developing mutually agreed-upon treatment goals.
• Notify NetCare of changes in Name, Address, Contact information, family status, loss of an identification card, selection of a Primary Care Physician (PCP) or other medical insurance coverage that you or your family members may have.
• Schedule appointments, arrive on time for scheduled visits, and notify your healthcare provider if you must cancel or be late for a scheduled appointment.
• Contact NetCare within 48 hours upon receiving emergency care outside NetCare’s service area.
• Contact Primary Care Physician before seeking any specialty physician/service.
• Log in to MyNetCare portal or call Customer Service when you have a question about your eligibility, benefits, claims and more.
• Log in to www.netcarelifeandhealth.com or call Customer Service before receiving services to verify that your doctor or health care professional participates in NetCare Health’s provider network.
• Choose a Primary Care Physician (PCP) for each person listed on the member ID card.
• Maintain a relationship with a PCP, as the PCP will act as the coordinator for all of your health care needs.
• Pay any necessary co-payments in accordance to the “Schedule of Benefits” at the time treatment/service is received.
• Be courteous and respectful of NetCare employees, providers, and their staff.

An Explanation of Benefits (EOB) will be mailed to you after your claim has been processed or you may also obtain an electronic copy of your EOB via our website at www.netcarelifeandhealth.com and logging into the Member portal. The EOB tells you how we processed the claim, including the services performed, the amount charged, our eligible charge, the amount we paid and the amount, if any, that you owe as a member. If we denied the claim or any part of it, the EOB will provide an explanation of the reason for the denial.

Please be sure to retain your EOB for filing with your secondary insurance carrier when applicable.

If you have any questions about your EOB, or think that we may have made an error in paying a claim, please contact or write to our Customer Service Department providing details as to why you feel the claim was processed in error. If, after contacting the Customer Service Department, you are not satisfied and think that we made an error in determining benefits or paying your claim, you may request a formal review by writing to us within 180 days of the date the claim was paid.

As a NetCare Plan member, you are required to obtain an approved referral from NetCare to seek off-island medical care outside of Guam. Please be informed that NetCare will not be financially liable for claims incurred outside of Guam if a NetCare approved referral is not obtained and authorized.

We encourage members to contact our Off-island Care Coordinators so we may assist you with arrangements and making appointments for medical care off-island. NetCare has a Medical Liaison Office in Manila to help coordinate your care while in the Philippines.

By allowing us to assist you, we can verify provider status and benefit coverage. It is important to note that when self-referring off-island, you must ensure that the facility and provider, or attending physician or laboratory etc.. are all in the participating provider network in order to avoid additional out-of-pocket expenses for services rendered by a non-participating provider. 

For services in Hawaii through Straub Clinic and Kapiolani Medical Center, you must contact our off-island care coordinators for appointment assistance and coordination with the Hawaii Pacific Health’s Liaison Office. Please allow 2 to 4 weeks for appointment scheduling at either Straub Clinic and/or Kapiolani Medical Center.

In addition, NetCare has contracted with AXA Assistance utilizing the United HealthCare Group network to provide global emergency assistance and worldwide provider access to over 600,000 international providers in over 130 countries including over 1.2 million provider facilities through the United HealthCare Network in the United States mainland.

NetCare also has direct contracted agreements with the following providers:

PHILIPPINES

• St. Luke’s Medical Center Quenzon City
• St. Luke’s Medical Center Global City
• Makati Medical Center
• The Medical City Medical Center
• Cardinal Santos Medical Center
• HealthCube
• Healthways Medical Clinic
• Philippine Heart Center

CALIFORNIA

• Anaheim Regional Medical Center
• Good Samaritan Hospital in Los Angeles
• The Doctor’s Medical Center in Modesto
• KPC Healthcare, Inc. (Orange County Global Medical Center,
Anaheim Global Medical Center, South Coast Global Medical Center,
Chapman Global Medical Center) – effective September 1, 2015

HAWAII

• Straub Clinic and Hospital
• Kapiolani Medical Center for Women and Children

As a NetCare member, you have access to a wide variety of participating providers on Guam, CMNI, Hawaii, Philippines, Asia and throughout the Continental United States depending on the benefit plan you are enrolled under.

We encourage you to choose your physician from our extensive network of participating providers to serve as the foundation for your health needs and to help reduce your health care costs in the long run.

Finding one is simple. Search through our Netcare PPO Provider Directory, Advantage Plan Provider Directory, CNMI Plans Provider Directory to find a physician or clinic that is convenient for you and your family.

Your benefits are meant to be used within the service area. However, we do recognize that you may also prefer to seek treatment outside of the service area. Therefore, we do have a contractual arrangement with participating providers off-island should you desire or need urgent or emergency care while outside of the service area.

You may also log on to www.whyuhc.com/netcare to access and locate a U.S. Mainland Participating Provider.

For assistance with off-island referrals, please contact NetCare’s Customer Service Department at 472-3610.


Participating Provider Directory

NetCare requires members enrolled under the Point of Service (POS) and HMO Plans to select a Primary Care Physician (PCP) for each member of the family. Your primary care physician will be the doctor you access for all of your day to day healthcare needs. Through regular screenings and wellness education, your PCP can prevent or manage health problems and coordinate referrals to specialists when necessary. A good relationship with your PCP can help ensure continuity of care and peace of mind for you and your family.

You may select an independent physician or a medical clinic from the Participating Provider Directory. You may not select a specialist as your PCP. If you select a clinic, you may see any primary care physician in that clinic, but if you see a specialist within the clinic, the specialist co-payment will apply.

Effective March 1, 2010 NetCare will allow members enrolled under our Advantage POS and HMO plans to make PCP changes anytime within the month to be effective the same day of your PCP election or incurred service.

Changes can be made through written request, telephone or email with our Customer Service Department or with your Marketing Representative. PCP change requests will be made effective the same day of the request. Requests for retroactive PCP changes will not be accepted however.

Members who are authorized to make PCP changes include the subscriber or any adult dependent. A subscriber may make changes for self and dependents. Dependent spouse may make changes for self and children. Overage dependent children (ages 18-22 years) may make changes for self only.

Primary Care is defined as general practice; family practice; pediatrics; internal medicine.

The Affordable Care Act ensures a member’s right to an internal appeal or asks NetCare to reconsider its decision to deny payment for a service or treatment. The law also permits the member to have an independent review organization (an external review) decide whether to uphold or overturn NetCare’s internal appeal decision. NetCare uses guidelines from the Uniform Health Carrier External Review Act to assure a member has the opportunity for an independent review of an a dverse determination or final adverse determination

If a claim is denied, in whole or in part, NetCare will furnish notice to the member specifying reason or describe any additional information required in perfecting the claim and the member’s right to file an internal appeal. If the member wishes to review and discuss the reason for the denial, a request must be made in writing to NetCare within one hundred eighty (180) days of receipt of a denial notice. NetCare will re-evaluate the claim in question and give a final written decision on the re-evaluation within sixty (60) days for services already incurred, thirty (30) days for non-urgent care not yet received, or seventy two (72) hours for urgent care, after such request is received.

A grievance, a complaint about NetCare’s operations, will follow same appeal process and timeline.

NOTICE OF APPEAL AND GRIEVANCE RIGHTS

A member has the right to appeal any decision we make that denies payment on a claim or a request for coverage of a health care service or treatment or of the plan’s operations

A member may request more explanation when a claim or request for coverage of a health care service or treatment is denied or the health care service or treatment a member received was not fully covered

A member can contact our office at 671-472-3610 when the following is applicable or occurs:

• Do not understand the reason for the denial;
• Do not understand why the health care service or treatment was not fully covered;
• Do not understand why a request for coverage of a health care service or treatment was denied;
• Cannot find the applicable provision in your Policy Specification;
• Want a copy (free of charge) of the guideline, criteria or clinical rationale that we used to make our decision; or
• Disagree with the denial or the amount not covered and you want to appeal.

If a claim was denied due to missing or incomplete information, a member or his/her health care provider may resubmit the claim to us with the necessary information to complete the claim.

APPEALS AND GRIEVANCES

All appeals or grievances for claim denials (or any decision that does not cover expenses a member believes should have been covered) or of NetCare’s operations must be received, in writing, by our NetCare Appeal & Grievance Procedures 2017 office at 424 W. O’Brien Drive, Suite 200, Hagatna, Guam 96910 within 180 days of the date you receive our denial or operational occurance. We will provide a full and fair review of the claim by individuals associated with us, but who were not involved in making the initial denial of the claim. A member may provide us with additional information that relates to a claim and a member may request copies of information that we have pertaining to his/her claim. We will notify the member of our decision in writing within 60 days of receiving your appeal. If a member does not receive our decision within 60 days of receiving the appeal, a member may be entitled to file a request for an external review

When a member appeals a claim, NetCare must give you its decision within:

1. Urgent Care Claims – 72 Hours Reply Time
   A special kind of pre-service claim that requires a quick decision due to a health condition that may be threatened. If your appeal concerns urgent care, you may be able to have the internal appeal and external review take place at the same time
2. Pre-Service Claims – 30 Days Reply Time
   Denials of non-urgent care you have not yet received.
3. Post-Service Claims – 60 Days Reply Time
   Claims for benefits under NetCare, including claims after medical care have been provided, such as reimbursement or payment of the costs of the services provided

EXTERNAL REVIEW

If we have denied your request for the provision of or payment for a health care service or course of treatment, you may have a right to have our decision reviewed by in dependent health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review within four (4) months after the date you receive our denial to Guam Department of Revenue and Taxation, Office of the Insurance Commissioner, 1240 Army Drive Barrigada, GU 96921, telephone 671-635-1844. For standard external review, a decision will be made within forty-five (45) days of receiving your request. If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an expedited external review of our denial. If our denial to provide or pay for health care service or course of treatment is based on a determination that the service or treatment is experimental or investigation, you also may be entitled to file a request for external review of our denial. For details, please review your Benefit Plan Document or contact our office at 671-472-3610, 424 W. O’Brien Drive, Julale Center Ste 200, Hagatna, GU 96910.
Expedited External Review - An expedited process if you have a medical condition where the timeframe for completion of a standard external review, pursuant to the Uniform Health Carrier External Review Act, would seriously jeopardize your life or health or ability to regain maximum function. A decision will be made expeditiously as your medical condition or circumstances requires, but in no event more than seventy-two (72) hours after the date of receipt of your request.