HMO Quick Tips

Not to be used instead of reading your Member Handbook but, as an additional tool.

Standards for physician accessibility for office appointment

• Life threatening Immediate
• Urgent Care Within 24 hours
• Routine or non-urgent:
• Primary Care Within 2 weeks
• Specialty Care Within 4 weeks
• Routine physical exam Within 5 months
• Routine GYN exam Within 5 months

Phone Access: Members should be able to reach their attending physician (or designatedon-call physician) by phone within thirty (30) minutes for emergent/ urgent care needs, 24 hours a day. For other services, members should be able to reach their attending physician within 4 hours.

Routine Care

• Call Primary Care Physician (PCP) office
• Announce you are CHA/HMO and your specific healthcare need
• You will be scheduled in the appropriate time frame
• At the office, show your CHA/HMO ID Card and be prepared to pay copayment

Urgent Care

• Call PCP (on-call physician = PCP)
• Announce you are CHA/HMO and your urgent need
• You will be directed to appropriate service (PCP office, BMH ER, or Southway Urgent Care)
• Show your CHA/HMO ID Card at the facility and be prepared to pay copayment

Emergent Care

• Seek care at closest Emergency Room (BMH only, unless visiting out of town)
• Show your CHA/HMO ID Card and be prepared to pay copayment
• Notify PCP within 48 hours (and announce you are CHA/ HMO)
• If you are instructed to follow-up with a Specialty Care Physician (SCP), you must contact your PCP and get a "referral" prior to scheduled appointment with the SCP

Prescriptions

• Must go to a CHA provider Pharmacy only
• Show CHA/HMO card and pay copayment

All Healthcare services must be ordered by your PCP! (or by a SCP with proper "referral" in place)

Anytime you receive a bill that should be a covered service, call immediately!

Process or Utilization questions: call 751-3064 or pager 747-8450, ID# 698

Billing questions: first call the provider or facility that is billing you to assure they have your correct insurance information; if further assistance is necessary, call the member services number shown on your ID Card.