My Health
· 11
Times set to get care
when you need it
How long should it really take to get
a doctor visit? Not long at all. The
Department of Managed Health Care
requires that, as a member enrolled in
our plan, you get visits within certain
time frames.
You also have access to providers
24 hours a day, 7 days a week. The
goal is to make sure you get the
services you need as quickly as you
can. Below is the most current guide
for care (effective January 18, 2011).
TYPES OF VISITS
TIME FRAME
Emergency exams
Immediate access 24 hours a day,
7 days a week
Urgent exams
Within 24 hours of request
Nonurgent sick exams
Within 48 to 72 hours of request,
as needed
Routine care, nonurgent (primary care)
Within 10 business days of request
Nonurgent care with mental health care providers
who are not doctors
Within 10 business days of request
Nonurgent care with specialist doctors
Within 15 business days of request
Nonurgent care for ancillary services (services
for which charges are made in addition to
routine services)
Within 15 business days of request
You should know that:
•
Primary care providers (PCPs) are required to be available 24 hours a day by
phone, or services must be available through an on-call provider. They must
have triage and screening services. Triage is how they figure out the priority
for caring for patients based on how urgent the health problem is.
•
If the provider or answering service is not available right away, an answering
machine may be used to tell members with emergency health care needs to
call 911 or to go directly to the nearest emergency room. The provider must
answer messages within 30 minutes.
•
Members also can call your health plan’s nurse line for answers
about:
•
Health concerns.
•
Triage and screening.
•
Prescription
drugs.
•
Local health care services.
•
Where to go for the right health
care services.
•
The waiting time for the visits may be longer if a provider needs to refer
you to someone else. It could also be longer if the treating doctor or the one
giving triage or screenings needs extra time.
•
Providers must act within the scope of their medical license.
•
Providers must note in the record that a longer waiting time will not harm
your health.
•
When you or a provider needs to reschedule an office visit, the provider
must reschedule it within a time that is right for your health care needs. The
provider must be sure care continues.
Please call us at the number on your member ID card if you have problems
getting care or services within waiting time frames.
Speak to a nurse anytime of day
Problems don’t just crop up between 9 a.m. and 5 p.m. Sometimes you’re miles from
the doctor’s office. Or it’s late at night when your child gets a high fever. What
should you do?
You can reach a registered nurse – for free – anytime of the day or night from
anywhere in the U.S. Simply call our 24/7 NurseLine at
1-800-224-0336
. Add
this number to your cell phone contacts today. If you have hearing or speech loss,
call
1-800-368-4424
.
Nurses have been carefully trained to help you figure out the care you need or what
to do next. If you have a true emergency, always call 911 first or go to the nearest
emergency room right away. A true emergency comes on suddenly and shows
severe symptoms.
If it’s not an emergency, call your doctor or the number above. One easy call can
help you make the right choice about where to go and how to get the care you need.
See the back page of the newsletter for languages that some written materials like
your handbook, claims and benefits letters come in.
Have a great local doctor? Do tell!
In a recent survey, members shared concerns about doctor choices. We hear you
and are working to add doctors to your plan. Is there a doctor you would like to be
part of the provider network? We want to know. Just call us at
1-800-407-4627
. Tell
us the doctor’s name. We will check to see if he or she can join the network. Also,
be sure to let us know if you are having trouble getting the care you need. You can
always call the number above and ask for help getting your doctor visit.
How to get a paper copy of our latest notices
If you want a paper copy of the updates in this newsletter or the latest Member Services
Guide, call us at
1-800-407-4627
. If you have hearing or speech loss, call the TTY line
at
1-888-757-6034
.
