Access to Specialty Care. 6.14.1 The Contractor must provide all medically necessary specialty care for Enrollees in a service area. If an Enrollee needs specialty care from a type of specialist who is not available within the Contractor’s provider network, or who is not available to provide the medically necessary services required by the Enrollee within the time frame described in subsection 6.2 of this Contract, the Contractor shall arrange for the necessary services with the nearest qualified specialist outside the Contractor’s provider network, who is willing to see the Enrollee.
Access to Specialty Care. If clinically appropriate, your PCP or WPHCP will refer you to a specialist, usually within the same medical group as your PCP. If the member’s preferred network specialist does not have a referral arrangement with your PCP/WPCHP, you may choose a new PCP/WPCHP with whom the specialist has such an arrangement. You can ask your PCP for a standing referral for conditions that require ongoing care from a specialist physician. Standing referrals may be made for a specified number of visits or a time period up to one year. Specialist copays may differ, depending on plan design. Out-of-Area Coverage When you are out of state, urgent care and hospital emergency room services are available through a network of contracting Blue Cross and Blue Shield providers. When you are out of state for a minimum of 90 consecutive days, guest membership may be arranged in participating communities throughout the U.S. with the Guest Membership Coordinator. Financial Responsibility You are responsible for copayments at time of service, as shown in the Description of Coverage. You are also responsible for payment for care not provided or coordinated by your PCP or WPHCP, except where otherwise noted. You should contact your employer’s benefit administrator to confirm the level of your contribution to the premium. Continuity of Treatment (Transition of Care) If a physician you are currently obtaining services from leaves the HMO network, you have the right to request transition of care benefits. To qualify for transition of care services, you must currently be undergoing a course of evaluation and/or medical treatment or be in the second or third trimester of pregnancy. The ongoing evaluation and/or medical treatment concerns a condition or disease that requires repeated health care services under a physician’s treatment plan, with the potential for changes in a therapeutic regimen. Transitional services may be authorized for up to 90 days from the date the physician terminated from the network. Authorization of services depends on the physician’s agreement to comply with contractual requirements and submit a detailed treatment plan, including reimbursement from the HMO at specified rates and adherence to the HMO’s quality assurance requirements, policies and procedures. All care must be transitioned to your new HMO PCP in the medical group/IPA after the transition period has ended. Coverage will be provided only for benefits outlined in your Certificate. Existing members: Submit a ...
Access to Specialty Care. CONTRACTOR shall provide for availability of necessary covered specialty care for Enrollees in a Service Area. If an Enrollee needs specialty care from a specialist who is not available within CONTRACTOR’S Participating Provider network, CONTRACTOR shall provide the necessary services with a qualified specialist outside CONTRACTOR’S Participating Provider network without additional expense (except applicable coinsurance or copayment amounts) to the Enrollee and to HCA.
