If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision. If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider and managing your care. For more assistance, contact Member Services at the number on the back cover of this book. Section 2.4 How to get care from out-of-network providers Under certain circumstances members may obtain services from out-of-network providers. Newly eligible members who are undergoing an existing course of treatment under the care of an out-of-network provider at the time of eligibility may continue to obtain services from that provider. Out-of-network providers with members under a current treatment plan must notify the health plan and request authorization of services as appropriate according to the Plan benefits. Once the health plan is notified that the member is under the care of an out-of-network provider, the provider must submit a request for authorization. All supporting clinical information must be provided to substantiate the continuation of the requested service(s). During this time existing care will not be interrupted until clinical information is reviewed for medical necessity and appropriateness. In the case where there may not be a network specialist available to the member, an out-of-network provider may be accessed at the discretion of the PCP. SECTION 3 How to get covered services when you have an emergency or urgent need for care or during a disaster Section 3.1 Getting care if you have a medical emergency What is a and what should you do if you have one? “medical emergency” A is when you, or any other prudent layperson with an average “medical emergency” knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. If you have a medical emergency: Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do need to get approval or a not referral first from your PCP.
If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision. If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider and managing your care. For more assistance, contact Member Services at the number on the back cover of this book. Section 2.4 How to get care from out-of-network providers Under certain circumstances members may obtain services from out-of-network providers. Newly eligible members who are undergoing an existing course of treatment under the care of an out-of-network provider at the time of eligibility may continue to obtain services from that provider. Out-of-network providers with members under a current treatment plan must notify the health plan and request authorization of services as appropriate according to the Plan benefits. Once the health plan is notified that the member is under the care of an out-of-network provider, the provider must submit a request for authorization. All supporting clinical information must be provided to substantiate the continuation of the requested service(s). During this time existing care will not be interrupted until clinical information is reviewed for medical necessity and appropriateness. In the case where there may not be a network specialist available to the member, an out-of-network provider may be accessed at the discretion of the PCP. SECTION 3 How to get covered services when you have an emergency or urgent need for care or during a disaster Section 3.1 Getting care if you have a medical emergency What is a “medical emergency” and what should you do if you have one? A “medical emergency” is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. If you have a medical emergency: Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.
H4093_ISNP_HMO_NONPOS_Model_wRx_v2-PA_EOC.docx