Accessing Care Clause Samples

Accessing Care. Members are entitled to Covered Services only at GHC Facilities and from GHC Personal Physicians. Except as follows:

Accessing Care. 1. Members are entitled to Covered Services only at KFHPWA’s Core Network (Network) Facilities and from KFHPWA’s Core Network (Network) Providers, except for Emergency services and care pursuant to a Preauthorization.

Accessing Care. ‌ 1. Members are entitled to Covered Services only at Core Network (Network) Facilities and from Core Network (Network) Providers, except for Emergency services and care pursuant to a Preauthorization.

Accessing Care. Members are entitled to Covered Services from either: • GHO’s Managed Health Care Network, referred to as “MHCN,” or • Community Providers or Preferred Community Providers on a Self-Referred basis. Members may choose either health care delivery option at any time during or for differing episodes of illness or injury, except during a scheduled inpatient admission. Benefits paid under one option will not be duplicated under the other option. Under the Agreement, the level of benefits available for services received at or upon Referral by the MHCN is generally greater than the level of benefits available for services received from Community Providers. In order for services to be covered at the higher benefit level, services must be obtained by MHCN Providers at MHCN Facilities, except as follows: • Emergency care, • Self-Referral to women’s MHCN health care providers, as set forth below, • Visits with MHCN-Designated Self-Referral Specialists, as set forth below, • Care provided pursuant to a Referral. Referrals must be requested by the Member’s MHCN Personal Physician and approved by GHO, and • Other services as specifically set forth in the Allowances Schedule and Section IV. Some services are covered only when obtained from or upon Referral by the MHCN. All inpatient admissions prescribed by a Community Provider must be authorized in advance by GHO. Members may refer to Sections IV.A. and IV.C. for more information about inpatient admissions.

Accessing Care. This plan makes available to you sufficient numbers and types of Providers to give you access to all covered services in compliance with applicable Washington State regulations governing access to Providers. Our Provider network includes primary care providers, specialty physicians, Hospitals, and a variety of other types of Providers. Members of this plan may receive care from either In‐Network or Out‐of‐Network Providers at any time. This plan’s benefits and your Out‐of‐Pocket Expenses depend on which Providers you see. With the exception of emergencies, you can control your Out‐of‐Pocket Expenses by choosing to seek care from In‐Network Providers. If you receive care from a Non‐Network Provider, you are always responsible for and will be billed for any amounts that exceed the Allowed Amount (this is known as “balance billing”).

Accessing Care. ‌ 1. Members are entitled to Covered Services only at Core Network (Network) Facilities and from Core Network (Network) Providers, except for Emergency services and care pursuant to a Preauthorization. Benefits under this Benefits Booklet will not be denied for any health care service performed by a registered nurse licensed to practice under chapter 18.88 RCW, if first, the service performed was within the lawful scope of such nurse’s license, and second, this Benefits Booklet would have provided benefit if such service had been performed by a doctor of medicine licensed to practice under chapter 18.71 RCW. DRAFT A listing of Network Personal Physicians, specialists, women’s health care providers and KFHPWA- designated Specialists is available by contacting Member Services or accessing the KFHPWA website at ▇▇▇.▇▇.▇▇▇/▇▇. See the Definitions Section XII. for more information on these providers. If you are visiting in the service area of another ▇▇▇▇▇▇ Permanente region, visiting member services may be available from designated providers in that region if the services would have been covered under this Benefits Booklet. Visiting member services are subject to the provisions set forth in this Benefits Booklet including, but not limited to, Preauthorization and cost sharing. For more information about receiving visiting member services in other ▇▇▇▇▇▇ Permanente regional health plan service areas, including provider and facility locations, please call ▇▇▇▇▇▇ Permanente Member Services at (▇▇▇) ▇▇▇-▇▇▇▇ in the Seattle area, or toll-free in Washington, ▇-▇▇▇-▇▇▇-▇▇▇▇. Information is also available online at ▇▇▇.▇▇▇.▇▇▇/▇▇▇▇/▇▇▇▇▇▇/▇▇▇▇▇▇▇▇/▇▇▇▇▇▇▇▇▇.

Accessing Care a) Basic services are accessed via multiple entry points into care, including: i referrals from designated school personnel such as counselors, psychologists, and social workers for ▇▇▇▇▇ HEARTTM services as needed. Upon receipt of the referral, Contractor case management team members will then reach out directly to the student’s parent/guardian to explain services and obtain consent. ii Referrals from ▇▇▇▇▇ Health medical providers who identify concerns during urgent care visits; and iii Request for services from parents/guardians. b) For visits conducted within the school building, students go to the designated private area in their school (which is monitored by a trained visit initiator who is a member of the school t personnel; the Contractor provides the training). The student then communicates with the provider using the ▇▇▇▇▇ App on the iPad. c) For visits that take place within the student’s residence; students and guardians access the system using the guardian’s mobile device or desktop computer (internet access is required). In cases where an unscheduled visit is required during the school day, students can see a provider within 3 minutes. Much like accessing the school nurse or health aide available during regular school days, students who need services outside of regular operating hours will need to contact local emergency services during evenings and weekends during the school year, student holidays/vacations, and summer breaks. d) Physical Healthcare 7am – 5pm EST, Monday through Friday. Mental Healthcare 7am – 7pm EST, Monday through Friday.

Accessing Care. Your Member ID Card You must present your ▇▇▇▇▇▇ Permanente member ID card, and a photo ID whenever you get Services. Your member ID card identifies you as a ▇▇▇▇▇▇ Permanente member. If you misplace or lose your card, call Member Services so that a new card can be sent to you. Our phone numbers are listed in the back of this Guide.