Servces List
Berkshire Health Partners, a Preferred Provider Organization, service area includes Berks, Upper Bucks,
Carbon, Lancaster, Montgomery, Northampton, and Schuylkill counties. Through relationships with third-party
administrators, insurance carriers, and insurance brokers, employer groups can access our valuable services
encompassing: medical and case management; a comprehensive network of credentialed physicians, hospitals,
and outpatient facilities; Wellness and Disease Management, Short-Term Disability Certification, and
Pennsylvania’s Preferred Health Networks, a statewide PPO network.
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Our provider network gives members access to over 3300 physicians, hospitals, medical equipment suppliers,
and home health care agencies. Our network of providers delivers healthcare services at negotiated rates and
are credentialed based on NCQA standards. In-network referrals are no required, allowing members freedom of
choice in their healthcare options.
Our provider discounts are very competitive. Participating providers are contracted to accept the Berkshire Health Partners
fee schedule as the total payment for any covered medical services, and are not permitted to balance bill the patient to
collect the difference, unless the plan design requires a deductible or co-insurance.
Our repricing department accepts both hard copy and EDI claims from our provider network. Our efficient repricing service
affords contracted employer groups accurate discounting of participating provider services. Claims are quickly turned around
and forwarded to the appropriate third party administrator (TPA) or insurance company for benefit determination and claim adjudication.
The medical management arm of Berkshire Health Partners, closely monitors the medical necessity and appropriateness of treatment
for our members. Reviews are conducted prospectively, concurrently, and retrospectively by nurse case managers who use medical
reso8urces and evidence based
Through relationships with nationally
known vendors; Medicus is able to offer comprehensive, state-of-the-art wellness and disease management vendors. By offering these
services, Medicus can help employer groups control the rising cost of health care related to hose members with chronic conditions.
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