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 ´┐ŻYour Primary Care Provider´┐Ż). 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
´┐Ż 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.
´┐Ż If the Plan finds it necessary to use providers outside the network and approves this decision in writing.
´┐Ż 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
´┐Ż If a Member´┐Żs health care provider leaves the Plan´┐Żs network for reasons unrelated to quality of patient care, fraud, or disciplinary action.
´┐Ż If a new Member has a life threatening or degenerative and disabling condition or disease.
´┐Ż 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 ´┐ŻAccessing Out-of-Plan Benefits´┐Ż and Section XI ´┐ŻPre- Authorization´┐Ż with deductibles and co-insurance described in the ´┐ŻSummary of Benefits´┐Ż.