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 Aetna Out-of-State Network


PEIA PPB Plans A & B

The PEIA PPB Plans provide care through several networks of providers. In West Virginia, any properly licensed health care provider who provides health care services or supplies to a PEIA participant is automatically considered a member of our network. Outside West Virginia, PEIA uses Aetna® Signature Administrators PPO to provide care for members of PEIA PPB Plans A, B and C. In addition, HealthSmart contracts with some out-of-state providers to serve PEIA PPB Plans A, B and C participants only. To locate a network provider, call HealthSmart at 1-888-440-7342 or 304-353-7820. For PEIA PPB Plans A, B and C, care provided by non-network providers requires prior approval, or it will be paid at the lower out-ofnetwork
benefit level (typically 60% of PEIA’s maximum allowance with the additional out-of-network deductible). Not
all providers in these networks may participate with PEIA. Kings Daughters Medical Center and Our Lady of Bellefonte hospitals in Kentucky and UPMC Health System remain out-of-network for PEIA, regardless of their network status with the ASA PPO network. Also, PEIA does not use the ASA PPO network in Washington County Ohio, or in Boyd County, Kentucky. PEIA reserves the right to remove providers from the networks, so not all providers in all networks may be available to you.

Resident Participants -- PEIA PPB Plans A & B participants who live in West Virginia or a bordering county of a surrounding state may access care from any of the following providers without receiving prior approval:

  • any West Virginia health care provider who provides health care services or supplies to a PEIA participant, or
  • any network provider located in those bordering counties
All services, except emergency care, provided outside of West Virginia beyond the bordering counties requires prior approval.

Non-Resident Participants -- For PEIA PPB Plans A & B participants who reside outside the State of West Virginia (beyond the bordering counties of surrounding states), PEIA has made special arrangements. Participants who live more than one county outside the State may seek care from any network provider. Care from network providers does not require prior approval, and that care will be covered at the in-network benefit level (typically 80%). Precertification of inpatient stays and certain outpatient procedures is still required. See page 40 for details.

PEIA PPB Plan C

The PEIA PPB Plan C provides care through several networks of providers. In West Virginia, any properly licensed health care provider who provides health care services or supplies to a PEIA participant is automatically considered a member of our network. Outside West Virginia, PEIA uses Aetna® Signature Administrators’ PPO. In addition, HealthSmart contracts with some out-of-state providers to serve PEIA participants only. To locate a network provider, call HealthSmart at 1-888-440-7342 or 304-353-7820. Care provided by non-network providers requires prior approval, or it will be paid at 80% of PEIA’s in-network allowed amount. You will be responsible for 20% of PEIA’s allowed amount, plus any difference between what the provider charges and what PEIA allows. 

Not all hospitals in Aetna Signature Administrators’ network may participate with PEIA. PEIA reserves the right to remove providers from the network, so not all providers in the network may be available to you.

Providers who are under sanction by Medicare, Medicaid or both are excluded from PEIA’s network for the duration of their sanction. Additionally, providers may be excluded from PEIA’s network based upon adverse audit findings.

If you have questions about a specific network provider, please contact HealthSmart at 1-888-440-7342.

Resident Participants -- PEIA PPB Plan C participants who live in West Virginia or a bordering county of a surrounding state may access care from any of the following providers without receiving prior approval:

  • any West Virginia health care provider who provides health care services or supplies to a PEIA participant, or
  • any network provider located in those bordering counties.
All services, except emergency care, provided outside of West Virginia beyond the bordering counties requires prior approval.

Non-Resident Participants -- For PEIA PPB Plan C participants who reside outside the State of West Virginia (beyond the bordering counties of surrounding states), PEIA has made special arrangements. Participants who live more than one county outside the State may seek care from any network provider. Care from network providers does not require prior approval, and that care will be covered at the in-network benefit level (typically 80%). Precertification of inpatient stays and certain outpatient procedures is still required.

PEIA PPB Plan D

PEIA PPB Plan D members have access to WV providers ONLY. For PEIA PPB Plan D, the only care allowed outside the State of West Virginia will be emergency care to stabilize the patient for transport back to a WV facility, and a limited number of procedures that are not available from any health care provider inside West Virginia. Plan D members must contact ActiveHealth when it appears that out-of-state care may be necessary. ActiveHealth will direct the patient to the appropriate facility to provide care – either in WV or out-of-state. Nonemergency care provided outside WV without approval from ActiveHealth IS NOT COVERED.

Providers who are under sanction by Medicare, Medicaid or both are excluded from PEIA’s network for the duration of their sanction. Additionally, providers may be excluded from PEIA’s network based upon adverse audit findings.

If you have questions about a specific network provider, please contact HealthSmart at 1-888-440-7342.


Follow the link below to access Aetna's Doc Find tool to find out-of-state network providers:

www.aetna.com/docfind/custom/asa

To start the prior approval process for out-of-state services, contact ActiveHealth at 1-888-440-7342.


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