How to Use This Health Plan Sample Clauses
The "How to Use This Health Plan" clause outlines the procedures and guidelines for members to access and utilize the benefits provided by their health insurance plan. It typically details steps such as how to find in-network providers, obtain referrals or pre-authorizations, and file claims for covered services. By clearly explaining these processes, the clause helps members understand how to effectively use their coverage and avoid unnecessary costs or denials, ensuring clarity and smooth access to healthcare services.
How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. This Blue Shield health plan is designed for Members to obtain services from Blue Shield Participating Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most services. Covered Services obtained from Non-Participating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider. Please be aware that a provider’s status as a Participating Provider or an MHSA Participating Provider may change. It is the Member’s obligation to verify whether the provider chosen is a Participating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Participating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Programs section for services outside of California. Blue Shield Participating Providers include primary care Physicians, specialists, Hospitals, Alternate Care Services Providers, and Other Providers that have a contractual relationship with Blue Shield. Participating Providers are listed in the Participating Provider directory.
How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Access+ HMO Providers is available online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Members may also call the Customer Service Department at the number provided on the back page of this EOC for assis- tance in selecting a Primary Care Physician. The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- ▇▇▇▇ Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- ▇▇▇▇▇▇▇. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below on Changing Primary Care Physicians or Designated Medical Group or IPA. The child must be enrolled with Blue Shield to continue coverage beyond the first 31 days from the date of birth or placement for adoption. S...