Specialist as PCP. If You have been diagnosed with a chronic, disabling, or Life-Threatening illness, You may contact customer service at the toll-free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO’s requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal the decision as described in Complaint and Appeal Procedures. If Your request is approved, the Specialist’s designation as Your PCP will not be effective retroactively. As used herein, “
Specialist as PCP. Some Specialists may act as a PCP for Members with a severe chronic, disabling, or life threatening medical Condition. This is permitted if the Specialist provides all basic Health Care Services and they are contracted with CHRISTUS Health Plan to perform PCP duties. Contact Member Services at 0-000-000-0000 to find out which Providers serve in both roles. CHRISTUS Health Plan Provider Directory Our Provider directory is a list of Physicians, Hospitals, pharmacies, and other Providers that are contracted with Us. The Provider directory is updated regularly. You can see the online Provider directory on Our website at xxx.xxxxxxxxxxxxxxxxxx.xxx. You can also call Member Services at 0-000-000-0000 and ask about a Participating Provider. ID Card You have been sent a Plan ID card. If more cards are needed, please call Member Services at 0- 000-000-0000. Always carry Your Plan ID card with You. The Plan ID card lists some of those benefits to which Members are entitled that may require Copayment amounts. Cost Sharing information can be found in Your the Schedule of Benefits. You are entitled to Plan benefits for Covered Services if all Premiums, Deductibles and Copayment amounts have been paid and You are eligible to get Plan benefits. Possession of a Plan ID card alone does not entitle You to benefits. Do not allow others to use Your Plan ID card. By doing so, You must pay for the services given to the non-Member. In addition, Your Plan Membership and that of Your covered Dependents, may be terminated. Call Member Services at 0-000-000-0000 immediately if Your Plan ID card is lost or stolen. Unauthorized, Fraudulent, Improper, or Abusive Use of Identification (ID) Cards WARNING: It is important to follow the advice of medical professionals and to receive the best care and treatment possible. This section does not provide any guidance or advisement for medical treatment and may not be interpreted as prescribed medical services. Do not use any information in this section to make decisions about your health care needs. This section is designed to provide general information to protect the unauthorized use of your medical benefits and ID card. The information can help raise awareness of strategies used by unscrupulous people to take advantage of you for financial gain. Also, in the event there is use of your ID card or health care benefits for anyone other than you, you are asked to make a report using the phone, fax or email listed in the next paragraph.
Specialist as PCP. If You have been diagnosed with a chronic, disabling, or life-threatening illness, You may contact customer service at the toll-free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO’s requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal the decision as described in Complaint and Appeal Procedures. If Your request is approved, the Specialist’s designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. Availability of Providers HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. Out-of-Network Services You may obtain Covered Services from Providers who are not part of HMO’s network of Participating Providers when receiving Emergency Care. Also, court-ordered Dependents living outside the Service Area may use non- Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non-Participating Provider, if approved by HMO. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers, but the following apply. • The request must be from a Participating Provider. • Reasonably requested documentation must be received by HMO. • The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition. • When HMO has allowed Referral to a non-Participating Provider, HMO will reimburse t...
