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What is a Primary Care Physician (PCP)?
A PCP is your "family doctor" and
coordinates all your medical care (except emergencies). Your PCP
will guide you through tests and treatments. If you need to see a
specialist or receive specialty services, your PCP will refer you to
the appropriate physician or facility. A PCP may be trained in
internal medicine, pediatrics, family practice or, in some cases,
obstetrics and gynecology. PCPs must be available to you 24 hours a
day or make arrangements for another physician to be available.
All your medical care must be coordinated or
arranged by your PCP. If you have any questions about your health,
call your PCP.
How do I choose a PCP?
Use the Find a Doctor
feature on this Wed site to identify doctors conveniently located
and available to you. You may call the doctor directly to find out
information about his or her practice. Once youÕve identified the
physician you would like to have as your PCP, use eMAMSI to tell us
your selection or call our Member Services Department at the
telephone number listed on your health plan identification card to
make your selection. You may select a different PCP for each person
in your family.
What if I want to change my PCP?
You may change your PCP by using our Online
Services, calling Member Services, or submitting a PCP Change Form
through the mail. If the Member Services Department receives your
new PCP selection on or before the 20th of the month, you can start
using your new PCP at the beginning of the next month. A new health
plan identification card will be issued to you with the name of your
new PCP. Be sure to check your new health plan identification card
to confirm your selecYou may changeted PCP.
In general, only a subscriber can make these
changes. To authorize another family member to make changes,
complete and send the Authorization
for Release of Health Information Form on our Web site or call
Member Services and request a copy of this form so you can complete
and return to us.
Remember, if you change your PCP and have a
referral to a specialist, you must get a new referral from your new
PCP.
Do I need a referral for all specialty care?
You need a referral from your PCP for all specialty
care except in certain circumstances such as eye refraction exams
and routine gynecological exams. Consult your Evidence of
Coverage for more complete information.
Be sure you understand the referral, including the
visits or procedures your PCP has authorized for your care. If the
service is not identified on the referral, your health plan will not
pay for it. If additional services are needed, the specialist must
contact your PCP and receive authorization for the services. You
will be financially responsible if you see a specialist without a
referral.
Am I covered for emergency care when I am
traveling out of the area?
You are covered by your health plan for a medical
emergency or urgent care situation while traveling away from home
and temporarily outside the health plan's service area. Routine or
elective medical services provided outside the service area are not
covered benefits even for college-age dependents attending school
outside the health plan's service area. Consult your Evidence of
Coverage for more details.
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Do I need a Primary Care Physician (PCP)?
No, but it is a good idea to select a PCP to help
coordinate your health care.
Do I need a referral for all specialty care?
No, you do not need a referral for specialty care.
You may see any physician participating (contracting) with your
health plan.
Can I see any doctor?
You may see any doctor who participates (contracts)
with your health plan. Use the Find a Doctor
feature on this Wed site to identify participating doctors
conveniently located and available to you.
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Do I need a Primary Care Physician (PCP)?
You do not need to select a PCP to use your
point-of-service (out-of-plan) benefits.
If you want to use your HMO (in- plan) benefits, you
will need to select a PCP. To find out more about your in-plan
benefits, please refer to the HMO Frequently Asked Questions.
Do I need a referral for specialty care?
When you use your out-of-plan benefits, you
do not need a referral for specialty care. Your out-of-pocket costs
will be higher than your in-plan benefits (refer to your Evidence of
Coverage, Group Certificate and all applicable riders and
endorsements for more detail).
When using your out-of-plan benefits, you can save
money if you use preferred physicians, health care practitioners and
facilities. Preferred physicians, health care practitioners and
facilities contract with your health plan and accept predetermined
payments as well as your applicable deductible, co-insurance or
copayment as payment in full. By using preferred physicians, health
care practitioners and facilities you will not be balance billed and
your applicable co-insurance and deductible may be lower.
Your certificate specifies your out-of-pockets costs
for preferred and non-preferred physicians. Our Member Services
Department can also give you this information.
If you decide to use your in-plan (HMO)
benefits, you will need a referral for most specialty care from your
PCP. See the Frequently Asked Questions about HMOs or your Evidence
of Coverage and all applicable riders and endorsements for more
detail.
Do some procedures and services require
pre-authorization or pre-certification?
Yes. All planned inpatient hospitalizations require
pre-authorization from your health plan. Some outpatient procedures
and services require pre-certification. These are specified in your
Group Certificate and any riders or endorsements.
Your doctor or health care practitioner should begin
the pre-authorization or pre-certification process. Show your doctor
your health plan identification card. On the card is a telephone
number to call for pre-authorization or pre-certification.
Please remember that it is your responsibility to
make sure your health plan has pre-authorized or pre-certified the
procedure or service before it is performed. If you receive a
procedure or service and it has not been pre-authorized or
pre-certified, you may be responsible for payment. Contact our
Member Services Department to verify that a planned inpatient
admission, procedure or service has been pre-authorized or
pre-certified.
If you have questions or concerns about our
pre-authorization or per-certification requirements, please call or
e-mail our Member Services Department.
Where should I send claims for reimbursement?
If you use your out-of-plan benefits and pay for the
service, complete the Claim Form (use link below) and submit
it directly to your health plan.
Member
Submission Claim Form
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I have PPO coverage with MLH. Do I need a
referral to see a doctor?
No. You can see any doctor you choose without a
referral.
Do I have to see a preferred physician?
No. You may see a preferred or a non-preferred
physician. You can save money if you use preferred physicians,
health care practitioners and facilities.
Preferred physicians, health care practitioners and
facilities contract with your health plan and accept predetermined
payments as well as your applicable deductible, co-insurance or
copayment as payment in full. By using preferred physicians, health
care practitioners and facilities you will not be balance billed and
your applicable co-insurance and deductible may be lower.
Your certificate specifies your out-of-pockets costs
for preferred and non-preferred physicians. Our Member Services
Department can also give you this information.
Do some procedures and services require
pre-authorization or pre-certification?
Yes. All planned inpatient hospitalizations require
pre-authorization from your health plan. Some outpatient procedures
and services require pre-certification. These are specified in your
Group Certificate and any riders or endorsements.
Your doctor or health care practitioner should begin
the pre-authorization or pre-certification process. Show your doctor
your health plan identification card. On the card is a telephone
number to call for pre-authorization or pre-certification.
Please remember that it is your responsibility to
make sure your health plan has pre-authorized or pre-certified the
procedure or service before it is performed. If you receive a
procedure or service and it has not been pre-authorized or
pre-certified, you may be responsible for payment. Contact our
Member Services Department to verify that a planned inpatient
admission, procedure or service has been pre-authorized or
pre-certified.
If you have questions or concerns about our
pre-authorization or per-certification requirements, please call or
e-mail our Member Services Department.
Where should I send claims for reimbursement?
If you use your out-of-plan benefits and pay for the
service, complete the Claim Form (use link below) and submit
it directly to your health plan.
Member
Submission Claim Form
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