Provider Directory Instructions for South Carolina
Plan Provider Directory
ProCare Advantage (HMO I-SNP)
This directory is current as of October 1, 2021
This directory provides a list of ProCare Advantage’s current network providers.
This directory is for ProCare Advantage’s residents of South Carolina.
Statement of Nondiscrimination and Alternate Formats
ProCare Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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This directory provides a list of ProCare Advantage’s network providers. To get detailed information about your health care coverage, please see your Evidence of Coverage (EOC).
You will have to choose one of our network providers in this directory to be your Primary Care Provider (PCP). Generally, you must get your health care coverage from your PCP. Your PCP works in collaboration with your ProCare Advantage Nurse Practitioner to assure you receive seamless, patient-centered care.
The network providers listed in this directory have agreed to provide you with health care services. You may go to any of our network providers listed in this directory; however, some services may require a referral. To obtain a referral, please contact your PCP or Nurse Practitioner.
For a complete listing of services that require prior authorization, or a referral, please refer to the Member Resources section of the ProCare Advantage website at ProCareAdvantagePlan.com or call our Member Services Department at 1-844-206-3719 (TTY 711).
About the ProCare Advantage Provider Network
Our network providers are the doctors, health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with ProCare Advantage to accept our payment and your cost-sharing amount as payment in full.
We have arranged for these providers to deliver covered services to members in our plan. The providers in our network bill us directly for the care they provide to you. When you see a network provider, you pay only your share of the cost for their services. You should use network providers for all your services.
Only in limited cases, may you receive covered services from out-of-network providers. These cases include:
- A medical emergency – go to the closest available provider
- Urgently needed services – go to any qualified provider when out of the Plan’s service area, or when network providers are unavailable
- Renal dialysis that you receive when you are outside the Plan’s service area
- Services that have been approved in advance by ProCare Advantage, and
- Any services which were covered through the appeals process
You should always see a network provider unless one of the limited cases mentioned above applies. If you choose to receive services from an out-of-network provider, they must request prior approval from ProCare Advantage unless it is an emergency to an acute care hospital.
If you receive a bill from an out-of-network provider, you should not pay the bill, unless you have received an Explanation of Benefits (EOB) that details what the plan will pay for your service, and any remaining balance you will need to pay. If you receive a bill from an out of network provider, but have not yet received an EOB, please submit the bill to ProCare Advantage or ask the provider to submit the bill to ProCare Advantage for you. The out-of-network provider may also bill you for any remaining balance not paid by ProCare Advantage.
If you have already paid for the covered services, ProCare Advantage will reimburse you for our share of the cost (if prior approval was obtained). If you have any questions, visit our “how to file an appeal” section of our website located at https://procareadvantageplan.com/for-members/exceptions-and-appeals/ or call our Member Services Department at 1-844-206-3719 (TTY 711).
Payment for services is contingent upon:
- The services you received are included in ProCare Advantage benefits as outlined in the Evidence of Coverage (EOC) that can be found on the plan website.
- The provider, or medical facility, you received services from is eligible for payment from ProCare Advantage.
- The service(s) meet requirements for medical necessity.
- An authorization or referral was obtained. Services for temporary out-of-network dialysis services when you are out of the service area does not require notification or preauthorization.
Note: Temporary out-of-network dialysis services when you are out of the service area, medical emergencies, and urgently needed medical services do not require notification or preauthorization for payment.
You must use plan providers except in emergency or urgent care situations. If you obtain routine care from out-of-network providers, neither Medicare nor ProCare Advantage will be responsible for the costs.
What is the service area for ProCare Advantage (HMO I-SNP)?
The counties in our service area are listed below for ProCare Advantage (HMO I-SNP):
- Fort Bend
How do you find ProCare Advantage providers that serve your area?
Step 1: Select your state to view in-network providers
Step 2: Select the type of provider you are looking for
Step 3: Search by a specialty, name of provider, name of facility, or by the office location (city, state or zip code).
You may get directions or view the location on a map by clicking the image of the map on the right side of the provider’s information on the details page.
If you have questions about ProCare Advantage, or require assistance in selecting a PCP, please call our Member Service Department at 1-844-206-3719 (TTY 711) or visit ProCareAdvantagePlan.com.