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.