In an HMO, it is important for you to understand how to access care, especially if you are injured or ill (See also Section IX “Your Primary Care Provider”). In most instances, if you require specialty care that is not an emergency, you will need a referral from your Primary Care Provider to a network specialist.
There may be times however when certain conditions warrant an exception to the standard referral process. In such cases, you have the right to request:
1. Standing Referrals - Members with conditions which require ongoing care from a specialist may request a standing referral to such a specialist.
2. Access to Specialist Care and Specialty Care Centers - A Member with (i) a lifethreatening condition or disease or (ii) a degenerative and disabling condition or disease either of which requires specialized medical care over a prolonged period of time may request:
(a) A specialist responsible for providing or coordinating the Member's medical care, and or
(b) Access to a specialty care center.
3. Access to Out-of-Network Providers
· If the Plan does not have a health care provider with appropriate training and experience in its network to meet the particular needs of a Member.
· If the Plan finds it necessary to use providers outside the network and approves this decision in writing.
· For a second medical opinion after a diagnosis of cancer (either negative or positive) or a recurrence of cancer or a recommendation for a course of treatment for cancer.
4. Transitional care by a non Network Provider
· If a Member’s health care provider leaves the Plan’s network for reasons unrelated to quality of patient care, fraud, or disciplinary action.
· If a new Member has a life threatening or degenerative and disabling condition or disease.
· If a new Member has entered the second trimester of pregnancy at the time of enrollment.
The MEMBER HANDBOOK describes the procedures to request access to these provisions while using in-Plan HMO benefits and the conditions and time frames under which approval will be given.
NOTE: If the Member is using out-of-Plan benefits as part of the Point of Service Plan, services will be allowed subject to Section VII “Accessing Out-of-Plan Benefits” and Section XI “Pre- Authorization” with deductibles and co-insurance described in the “Summary of Benefits”.