Choosing a Primary Care Provider (PCP)
One of the first things you will need to do when you enroll in our plan is choose a PCP. This can be a doctor, nurse practitioner, or a physician assistant. You will see your PCP for regular check-ups, shots (immunizations), or when you are sick. Your PCP will also help you get care from other providers or specialists. This is called a referral. You can choose your PCP by calling Member Services.
You can choose a different PCP for each family member or you can choose one PCP for the entire family. If you do not choose a PCP, we will assign a PCP for you and your family.
You can change your PCP at any time. To change your PCP, call Member Services.
If you have Medicare, please contact the number on your Medicare ID card for information about your PCP.
Choosing a PCP for Your Child
You can pick a PCP for your baby before your baby is born. We can help you with this by calling Member Services. If you do not pick a doctor by the time your baby is born, we will pick one for you. If you want to change your baby’s doctor, call us.
It is important that you select a PCP for your child to make sure they get their Child Health Check-ups each year. Child Health Check-ups are for children 0 – 20 years old. These visits are regular check-ups that help you and your child’s PCP know what is going on with your child and how they are growing. Your child may also receive shots (immunizations) at these visits. These visits can help find problems and keep your child healthy.
You can take your child to a pediatrician, family practice provider, or other health care provider.
You do not need a referral for Child Health Check-ups.
There is no charge for Child Health Check-ups.
Specialist Care and Referrals
Sometimes, you may need to see a provider other than your PCP for medical problems like special conditions, injuries, or illnesses. Talk to your PCP first. Your PCP will refer you to a specialist. A specialist is a provider who works in one health care area.
If you have a case manager, make sure you tell your case manager about your referrals. The case manager will work with the specialist to get you care.
You have the right to get a second opinion about your care. This means talking to a different provider to see what they have to say about your care. The second provider will give you their point of view. This may help you decide if certain services or treatments are best for you. There is no cost to you to get a second opinion.
Your PCP, case manager or Member Services can help find a provider to give you a second opinion. You can pick any of our providers. If you are unable to find a provider with us, we will help you find a provider that is not in our provider network. If you need to see a provider that is not in our provider network for the second opinion, we must approve it before you see them.
Urgent Care is not Emergency Care. Urgent Care is needed when you have an injury or illness that must be treated within 48 hours. Your health or life are not usually in danger, but you cannot wait to see your PCP or it is after your PCP’s office has closed.
If you need Urgent Care after office hours and you cannot reach your PCP, you can call our 24-hour Nurse Advice Line at 1-800-625-1512 or you can go directly to a participating urgent care center. You may also find the closest participating urgent care center to you by calling Member Services at 1-844-243-5176 or going to our website at www.lighthousehealthplan.com/providerdirectory.
If you would like to talk to your PCP’s office, the phone number is on the front of your ID card. Your PCP will have a doctor who monitors and returns calls also known as being “on call.” This doctor will call you back and tell you what to do. If you go to an urgent care center be sure to call your PCP the next day to ensure you get the follow up care you need.
If you need to go to the hospital for an appointment, surgery or overnight stay, your PCP will set it up. We must approve services in the hospital before you go, except for emergencies. We will not pay for hospital services unless we approve them ahead of time or it is an emergency.
If you have a case manager, they will work with you and your provider to coordinate services when you go home from the hospital.
You have a medical emergency when you are so sick or hurt that your life or health is in danger if you do not get medical help right away. Some examples are:
• Broken bones
• Bleeding that will not stop
• You are pregnant, in labor and/or bleeding
• Trouble breathing
• Suddenly unable to see, move, or talk
Emergency services are those services that you get when you are very ill or injured. These services try to keep you alive or to keep you from getting worse. They are usually delivered in an emergency room.
If your condition is severe, call 911 or go to the closest emergency facility right away. You can go to any hospital or emergency facility. If you are not sure if it is an emergency, call your PCP. Your PCP will tell you what to do.
The hospital or facility does not need to be part of our provider network or in our service area. You also do not need approval ahead of time to get emergency care or for services received in an emergency room to treat your condition.
If you have an emergency when you are away from home, get the medical care you need. Be sure to call Member Services when you are able and let us know.