Frequently Asked Questions - PPO

Sagamore Plus or Sagamore Select
Preferred Provider Organization (PPO)

Benefit plans vary widely. The information presented in this section is general in nature; is intended to be informational only and, as such, is superceded by your specific benefit plan. Please refer to your Benefit Plan Description, including all attached Certificate Riders, for complete details of coverage including benefit exclusions and limitations.

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We have tried to answer each question clearly. If you have a question not covered here or an answer we give to one of these questions is not clear, please use the Ask Us link and we will respond as soon as possible. Your question may also be added to this list to help others.

Please include one or all of the following when you send your question so that we can respond to you in the appropriate manner. Thank you!

Don't forget to include:

  • Your Name.
  • The e-Mail address to which you would like the response to go if different from the originating e-Mail address. We will automatically respond to the originating e-Mail address unless you include another "preferred" address.
  • Your Phone Number if you would like someone to call you.
  • Your mailing address if you are requesting a Provider Directory to be mailed to you.

Q. What is Sagamore Health Network, Inc.?

A. Sagamore is a managed health care company based in Indiana with over 290 hospitals and over 54,000 physicians and other medical care providers. We're committed to Indiana, so we work closely with local providers to provide our customers with a comprehensive and competitive network. Our hospitals are all JCAHO accredited and/or Medicare approved. All of our physicians are credentialed according to nationally recognized standards. Contrary to popular belief, in this role, Sagamore is not the insurance company. Sagamore's network is "accessed" through contracts with over 120 health insurance companies, third party administrators, self-insured firms and Health & Welfare trusts.

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Q. Why do claims have to be sent to Sagamore first before being forwarded to my health plan administrator?

A. When you use the services of a Sagamore network medical provider, the claim (bill) is sent to Sagamore to be re-priced based upon the fee that was negotiated with that provider. The re-priced claim (bill) is then forwarded to the payor (the insurance company or third party administrator) for processing based on the specific benefit provisions of the plan. Sagamore providers are obligated to write off the difference between their billed charge and the re-priced amount for covered services. The amount to be "written off" or "discounted" by the provider is normally spelled out in the Explanation of Benefit (E.O.B.) provided to both the provider and the member.

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Q. What is a Preferred Provider Organization (PPO)?

A. A PPO is a managed care arrangement created to offer quality, cost effective healthcare through a network of respected, well-established physicians, hospitals and other medical care providers.

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Q. What are the advantages of using a Preferred Provider Organization arrangement?

A. The Sagamore PPO network provides the following advantages to a member and/or dependents.

  • Save money when using Sagamore physicians because of receiving higher benefit levels and paying a smaller share of costs.
  • May still use any physician, even those outside the Sagamore Network if willing to share a larger portion of the cost for covered services and file claim forms.
  • There are no claim forms to file when using a Sagamore hospital or physician.
  • Unlike some HMO plans, members are not restricted to only Sagamore physicians. They may go to any physician or hospital of choice and still receive reasonable benefit coverage.

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Q. How can I tell if a physician is in the network?

A. You will receive a copy of a Sagamore Provider Directory. This directory is reprinted and updated once annually and physicians are continually added (and some removed) between reprints. To minimize potential problems and decrease costs for you, it is always a good idea to check the physician's network status before making an appointment. This can be done by calling Sagamore at (800) 364-3469. You are also able to get this information from the Sagamore web site by clicking on the Customized Provider Directory link.

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Q. As a Sagamore member, must I use only physicians and hospitals participating in the Network?

A. NO. You receive better benefit coverage by using the Sagamore providers. However, if you choose a non-participating provider, your benefits will be lower, so you will pay a larger portion of the cost. Unlike some health plans, you have the freedom to choose the hospital and physician that best meets your health care needs.

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Q. Does a PPO plan require that I select a Primary Care Physician (PCP) in advance?

A. A PPO plan does not normally require preselection of a PCP. In most plans, you can choose to use any physician at any time. Benefit levels, however, are subject to whether the provider is IN or OUT of the network.

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Q. What if I need Specialty Care? Can I choose the specialist? Must it be a Sagamore physician?

A. The decision is yours. Sagamore physicians should refer you to other Sagamore providers. If you choose to use an out of network physician or provider, however, bear in mind you will be subject to OUT of network benefits and will likely have to pay more out of your pocket.

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Q. Why does the care I receive in the Network cost me less than the care I receive outside the Network?

A. Costs are lower for covered services in the Network for the following reasons:

  • Participating providers agree to negotiated fees or discounts.
  • You are not balance billed for the difference between the negotiated fee and the actual charge.
  • Your share of the cost for medical service and co-insurance is lower for services rendered in the network.

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