USING THE HMO SYSTEM Sample Clauses

USING THE HMO SYSTEM. ‌ The HMO program is different from traditional health insurance coverage. In addition to covering health care services, the HMO actually provides access to a Member’s medical care through a Primary Care Physician (PCP). Members have the right to designate any PCP who participates in the network for Keystone’s Approved Service Area and who is available to accept new patients. For children, a pediatrician may be designated as the PCP. For information on how to select a PCP, and for a list of the participating PCPs, contact Keystone Customer Service. All medical treatment begins with the Member’s Primary Care Physician. Under certain circumstances, continuing care by a Nonparticipating Provider will be treated in the same way as if the Provider were a Participating Provider (See Continuity of Care appearing later Section VI in this Agreement.) Because a Member’s Primary Care Physician is the key to using the HMO program, it is important to remember the following:  A Member’s Primary Care Physician should always be called first before receiving Medical Care (except for conditions requiring Emergency Services). Please schedule routine visits well in advance.  When Specialist Services are needed, a Member’s Primary Care Physician will send an electronic Referral for specific care or will obtain a Preauthorization from the HMO when required. A Standing Referral may be available if a Member’s condition is life-threatening, degenerative or disabling disease or condition. Members do not need Preauthorization from Keystone or from any other person (including a Primary Care Physician) in order to obtain access to obstetrical or gynecological care from a health care professional in the network for Keystone’s Approved Service Area who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services following a pre- approved treatment plan, or procedures for making Referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Xxxxxxxx’s Customer. Primary Care Physicians must obtain a Preauthorization for Specialist Services provided by Nonparticipating Providers. It is important to note that all laboratory services must be obtained using the PCP’s laboratory arrangement listed on the Member’s ID Card.