Take Charge of Your Health
One of the first things you will need to do when your child enrolls in our plan is choose a primary care provider, or PCP. This can be a doctor, nurse practitioner, or a physician assistant. Your child will see his or her PCP for regular check-ups, shots (immunizations), or when your child is sick. Your child’s PCP will also help your child get care from other providers or specialists. This is called a referral. You can choose your child’s 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 your child. You can change your child’s PCP at any time. To change your child’s PCP, call Member Services at 1-855-463-4100.
Call your PCP office to schedule a visit, even if your child doesn’t need immediate medical care.
See your child’s PCP if your child needs:
- Help with colds, flus and fevers
- Care for ongoing health issues like asthma or diabetes
- A Well Child Visit
- Vaccinations
- General advice about your overall health
Tips for Making the Most out of Your Doctor’s Visit:
- If you don’t understand something, ask questions until you understand
- Encourage your child, if able, to talk about any health issues or symptoms
- Ask about next steps and schedule a follow-up appointment if needed
If you would like help finding a new primary care provider, call Member Services at 1-855-463-4100, or use our Find a Provider Tool.
When is it Time to Switch to a PCP from a Pediatrician?
Getting care that is right for your age and your health is important.
When your kids are young, they see a pediatrician. This is a doctor who knows all about kids’ health. But when they grow up, their health needs change. That is when it is time to move to a doctor who knows about adult health. Your doctor and your health plan can help you and your child make this change. If you need help finding a new doctor, talk with your doctor or call Member Services at 1-855-463-4100.
| PCP Appointment Type | Access Standard |
|---|---|
Urgent Care | Within 48 hours for service that does not require prior authorization and within 96 hours for services that do require prior authorization |
Regular and Routine Well Exam | Within 30 days |
After Hours Care | PCPs must offer after hours appointments |
| Specialist Appointment Type | Access Standard |
|---|---|
New Patient Appointment | Within 60 days of request with appropriate referral |
Routine Prenatal Exams | Within four weeks until week 32, every two weeks until week 36 and every week thereafter until delivery |
Oncology: New Patient Appointment | Within 30 days of request |
Follow Up After Physical Health Admission | Within seven days of discharge from the hospital |
| Behavioral Health Appointment Type | Access Standard |
|---|---|
Non-life Threatening Emergency | Within six hours |
Urgent Access | Within 48 hours |
Initial Visit for Routine Care | Within 10 business days |
Follow Up for Routine Care | Within 30 calendar days |
Follow Up After Behavioral Health Hospital Admission | Within seven calendar days |
After Hours | Your BH provider must have a call receiving service that is answered by a live person |