Accessing Routine & Specialty Care

This section of your online member handbook explains:

Why do I need a primary care physician (PCP)?
How do I find a PCP?
Does Priority Health need to approve any medical services I receive?
Does Priority Health need to approve visits to specialists or other doctors or hospitals?
Can I see my obstetrician or gynecologist without a referral?
What if I want to change doctors?


Q: Why do I need a primary care physician (PCP)?
Whether you need a PCP depends on your health plan. Priority Health requires PriorityHMO^SM, PriorityEPO^SM and PriorityPOS^SM members to choose a Primary Care Physician or other primary health care provider. Your PCP plays two roles in your care:

• Helping you stay healthy by coordinating all your health care services
  
• Helping you get health services covered by your health plan, so you pay less money out of your own pocket.

Everyone covered under your health plan can visit the same PCP, or each person can have a different one.

• PCP choices include internists, general practitioners, family practice doctors or physician assistants.
• Children can have a pediatrician as their PCP.
• Women can choose some obstetrician/gynecologists as a PCP, but not all OB/GYNs are also PCPs.
  

PriorityPPO^SM members: The choice is of providers is always yours, but we encourage you to select a primary doctor in our network to manage your health care, and to keep him or her informed of all your visits to specialists and other health care providers. A primary care doctor who knows your health history is your best resource for making sure you get the right care.

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Q: How do I find a PCP?
Go to the Find a Doctor tool online and search for "Primary Care Physician." It will ask you, "What kind of PCP meets your medical needs?" and you will be able to narrow your search to internists, family medicine, OB/GYNs, and other types of PCPs. You can also search for a PCP doctors by sorting your results by location and "apple" quality ratings - look for four apples, the highest rating. The Provider Directory you received from Priority Health also has a comprehensive listing of participating physicians.

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Q: Does Priority Health need to approve the medical services I receive in advance?
For some services you will need a letter of approval (pre-authorization) from us before you can receive care. Your doctor will probably request the authorization for you. Check this list of the types of services that generally need prior authorization from us before they can be covered. Or you can contact Priority Health to find out, since each employer's benefits are a little different.

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Q: Does Priority Health need to approve visits to specialists and other doctors or hospitals?
Coverage for referral care or visits to specialty providers and facilities depends on your health plan.

• PriorityHMO/EPO members: It's always a good idea to let your PCP know what other doctors you're seeing so he or she can better coordinate your care. You do not need a referral from your your Primary Care Physician to see network specialists or go to network hospitals. Use the Find a Doctor tool online to find network specialists and hospitals. Note: some specialists still require a referral from your PCP - but it's not a Priority Health requirement.
• PriorityPOS members: Your PCP coordinates all of your health care, including referrals to specialists and hospitals. To receive coverage at the Preferred Benefits level, call your PCP for a referral. To be sure the specialty care is covered, remember:
• Referrals are made for a fixed number of visits.
• Alternate Benefits will apply if you see a specialist without your PCP's approval. You may also have to pay for any charges.
• Your PCP should coordinate and approve all follow-up care following emergency treatment.
• PriorityPPO members: You do not need a referral from your primary doctor to visit a specialist. Just remember that if you visit a non-network specialist, the Non-Network Benefit level will apply, even if a network doctor refers you. And make sure your primary care doctor is informed of any treatments or drugs you are choosing.

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Q: Can I see my obstetrician or gynecologist without a referral?
Women can visit a obstetrician/gynecologist in the Priority Health network for an annual well-woman exam and for routine care while pregnant without a referral from their Primary Care Physician. Use the Find a Doctor tool online to find a participating OB/GYN, or check the Provider Directory you received from Priority Health.

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Q: What if I want to change my PCP?
You can change any time. To find a new PCP, use the Find a Doctor tool online to search for doctors who participate in your plan. Online, you can also search by specialty and by location. Once you choose a new PCP, there are three ways to let Priority Health know you want to change your PCP:

1. Log in to your member account here on priorityhealth.com and click "Change Your Doctor." Or:
2. Download the Change PCP form (29KB PDF) online, or get the form from your employer. Fill it out and return it to the address on the form.
   
3. Or you can call us and tell us who you're switching to.

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