Frequently Asked Questions (FAQs)
FOR FURTHER QUESTIONS CALL (866) 420-8575
No. Employee, spouse and children may see any in-network Primary Care Physician. The co-pay to see an ACTIN-contracted Primary Care Physician is $30.
Call the customer care line prior to procedure (866) 420-8575 so we can help you determine if your benefits will be considered Tier 1 (Actin Network/AMITA) – lowest out of pocket, Tier 2 (First Health PPO) – higher out of pocket, or Tier 3 (Non Contracted Provider) – very high out of pocket.
Go to the Actin Care website ww.actincare.com, scroll down to ‘Provider Look-Up’ and select ACTIN CHOICE select search by Facility or Provider look up.
SisCo may contact you after a Provider notifies the Pre-Certification department (refer to the back of your ID card for details) alerting you of the Benefit Tier for that particular Provider, i.e., Tier 1 (Actin Network/AMITA) – lowest out of pocket, Tier 2 (First Health PPO) – higher out of pocket, or Tier 3 (Non Contracted Provider) – very high out of pocket.
Please refer to the back of your ID card for information.
You may see a Primary Care Physician in the First Health Network at the same out-of-pocket cost as an ACTIN-contracted Primary Care Physician, $30 copay. Go to www.myfirsthealth.com to search for a Primary Care Physician. (The First Health Network logo and contact information will be on the ID Card for you to access).
Yes. However, you are REQUIRED to contact ACTIN CARE GROUPS to advise the name of the primary care doctor you will see. You will be responsible for paying the bill when you visit your doctor and you will be reimbursed at ACTIN’s median contracted rate for in-network physicians. You will be responsible for the difference, if any, in what the physician charges and the plan pays. You can submit your itemized billing statement to the claims address on the back of your card for reimbursement. It is important that you notify ACTIN CARE GROUPS with your primary care doctor information so claim reimbursements for this provider are processed correctly.
Ask your provider to refer you to ACTIN preferred labs; Quest Diagnostics, LabCorp, and Alverno Labs. You can find the logos on the back of your ID card as well.
No, any specialist in the ACTIN network and First Health network are covered for office visits only with a $60 copay. Deductibles and co-insurance apply to specialist services other than for an office visit.
To avoid unexpected costs, you MUST notify Actin Care Groups when a member is a STUDENT living OUT OF AREA and if you have an OUT OF NETWORK PCP.
Services for Dependents who live Out-of-Area (lives at least six (6) months of the year more than 25 miles from the Employee’s primary residence). Eligible Expenses while the Dependent is living Out-of-Area must be obtained from First Health PPO contracted providers during the period that the Dependent is residing more than 25 miles from the Employee’s primary residence and will be processed at the ACTIN Providers level of benefit. (The First Health Network logo and contact information will be on the ID Card for you to access). The website to search for a First Health provider for the dependent residing outside the area is www.myfirsthealth.com. Services rendered at NON-First Health PPO Contracted providers will result in additional costs to the insured.
NO. If an ACTIN network specialist performs an outpatient procedure at a First Health facility, the specialist’s fee is covered at ACTIN Network rates but the facility fee (which is typically 3 or more times the specialist’s fee) is paid at First Health co-insurance, deductibles and out-of-pocket maximums, which are much higher than ACTIN Network co-insurance, deductibles, and out-of-pocket maximums.
If an ACTIN network specialist performs an outpatient procedure at a facility that is neither in the ACTIN network nor the First Health network, the specialist’s fee is paid at ACTIN Network rates but the facility fee (which is typically 3 or more times the specialist’s fee) is paid at out-of-network rates, which have the highest co-insurance, deductibles, and out-of-pocket maximums.
In Boone, Cook, Dekalb, DuPage, Kane, Kankakee, Lee, McHenry, Stephenson, Will, and Winnebago Counties Physicians Immediate Care and AMITA facilities are all in the ACTIN network. You may locate the nearest Physicians Immediate Care facility at https://physiciansimmediatecare.com/locations/. AMITA urgent care facilities can be found at https://www.amitahealth.org/our-locations/immediate-care-centers or entering “AMITA Urgent Care” on a search engine. In McHenry County, Lake Immediate Care and Clinic 521 Kora Ln, Island Lake, IL 60042 and Med Express Urgent care 226 S Randall Rd, Algonquin, IL 60102 are also in the ACTIN network.
You may also access First Health Urgent care centers in Boone, Cook, Dekalb, DuPage, Kane, Kankakee, Lee, McHenry, Stephenson, Will, and Winnebago Counties but the co-insurance is greater than for ACTIN contracted urgent care centers.
IN-NETWORK Urgent care providers are in the First Health network when traveling outside the following counties: Boone, Cook, Dekalb, DuPage, Kane, Kankakee, Lee, McHenry, Stephenson, Will, and Winnebago (The PPO Network logo and contact information will be on the ID Card for you to access.) You can search www.myfirsthealth.com to find a First Health urgent care center outside the Chicago/Rockford areas.
You are covered at any hospital in an emergency. You may be asked to complete a financial assistance form after a Hospital or Emergency Room admission. If you are asked to complete this form and do so, your cost will not be more than your coinsurance and copays. If you decline to complete the financial assistance form (if asked), you will owe the difference in what the plan pays and the hospital charges in addition to applicable copays and coinsurance.
Emergency Room Care includes a facility copay plus coinsurance. The copay is waived if admitted. Note: ER visits are reviewed by an independent physician to determine if the condition was in fact an emergency. An “Emergency” is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: 1) a condition placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; 2) serious impairment to bodily functions; or 3) serious dysfunction of any bodily organ or part. Medically unnecessary ER visits are not covered. If unsure whether to go to the ER or Urgent Care, call the 24 hr. Nurse-line at 800-583-5888.
You are responsible for your share of the coinsurance amount.