For Parents of Child Health Plus Members
For Parents of Child Health Plus Members
For Medicaid and Family Health Plus Members
For Members of HIP Prime®,HIP HMO and HIP HMO Direct
For Members of HIP Prime®POS, HIP Choice Plus and HIP Choice Plus Direct
For Members of HIP VIP®Medicare Plan
For Members of HIPaccess I and HIPaccess II
What is the New Member ID/NMI?
1. What's the role of my child's Primary Care Physician?
The Primary Care Physician (PCP) is your child's personal physician. He or she provides your child's health care and/or refers your child to specialists when specialty services are needed. It's very important for you to understand that this plan will not usually cover care received without a referral from the PCP. There are a few exceptions, which are referred to in the answer to Question 4 below.
You should choose a PCP for your child within the first 30 days of enrollment. If you do not, HIP will assign your child to a PCP. Look on your child’s HIP Identification Card. The name and phone number of the assigned PCP are printed on the front of the card. You can decide to change the assigned PCP at any time. Begin by doing a Provider Search. Then Log In and follow the instructions for selecting and changing your child's PCP. If you need help, call HIP's Customer Service line at 1-800-HIP-TALK (1-800-447-8255).
2. Do I call my child’s PCP in an emergency?
Yes, unless it’s a life-threatening emergency. In a life-threatening emergency, you should call 911 and get help immediately. Keep in mind that your child’s plan does not cover use of hospital emergency rooms for non-emergency care. In non-emergency situations, call your child’s PCP for the help you need. To understand the meaning of "emergency," see the answer to Question 3 below.
3. What constitutes an emergency?
An emergency is a medical or behavioral condition that comes on all of a sudden, and has pain or other symptoms. The condition must be one that would make a person with an average knowledge of health fear that your child will suffer serious harm to body parts or functions or serious disfigurement without immediate care.
Examples of emergencies are:- A heart attack or chest pain.
- Bleeding that won't stop.
- A bad burn.
- Broken bones.
- Trouble breathing.
- Convulsions.
- Loss of consciousness.
Examples of non-emergencies are colds, sore throat, upset stomach, minor cuts and bruises or strained muscles.
4. What happens if I take my child to see a specialist without a referral from the PCP?
In most cases, going directly to a specialist without a referral is not covered. Your child receives benefits only for covered services given by the PCP or through referral by that doctor. There are a few exceptions. See the table below for services your child may access directly from a HIP participating physician without a referral from the PCP.
- Primary and preventive care from the PCP.
- Primary and preventive OB/GYN care, including mammography and cervical screenings.
- Outpatient mental health visits.
- Refractive eye exams from an optometrist.
5. Will my child’s PCP provide a referral to any doctor in the HIP participating network?
You can expect your child's PCP to refer you to specialists that he or she knows and trusts. In most cases, that means referrals to other physicians within the same medical center or medical group to which you child's PCP belongs. The exception is when the kind of care your child needs is not available from within the PCP's usual referral group. In that case, the PCP will find a qualified physician from the full HIP network to treat your child.
It's important to remember that all physicians develop these kinds of referral patterns. That's true regardless of their participation with HIP or with any other health plan. And this practice is very much in your child's best interest. When the PCP coordinates all your child's care, your child is protected against such problems as conflicting medications or duplicate procedures. These kinds of problems can occur when you refer your child to more than one physician.
So most people find it convenient and wise to follow the PCP's referral suggestions. If there is a particular HIP participating specialist whom you know you will want your child to see, check with that physician's office to find a participating PCP with whom this specialist regularly works. Then select the recommended PCP when you enroll your child.
6. Do I have to get prior approval from HIP before my child gets care?
No, you do not have to obtain prior approval from HIP before your child gets care. We’d like to take this opportunity to remind you that the primary responsibility for your child’s care rests in the hands of the PCP. If your child receives care from his or her PCP, or through referral from the PCP, the PCP will get any necessary approvals for you. (Sometimes, if your child has already been referred to a specialist, the specialist may secure the approval instead.) Only certain services require prior approval:
- All non-emergency inpatient hospital admissions, including hospital and nursing home care, rehabilitation, mental and behavioral health treatment, or skilled nursing facility care.
- Ambulatory surgery, except termination of pregnancy (in a hospital setting or freestanding surgical center).
- Home health care (nursing, physical therapy, occupational therapy, speech therapy and infusion therapy).
- Durable medical equipment (DME).
- Transplant evaluation and services.
- Hospice care.
- Outpatient cardiac and pulmonary rehabilitation.
- Outpatient diagnostic radiology services.
- All services provided by any non-participating provider/facility, except dialysis.
Even though the PCP or specialist will handle the request for prior approval, it’s a good idea to verify that the approval was actually obtained. Check with the office staff of the doctor who is recommending the care. (It’s also a good idea to call the office of any doctor your child has been referred to for confirmation that he or she still participates in the HIP network.)
7. How long should it usually take to get an appointment with a HIP participating physician?
We realize that when you decide to take your child to see a doctor, you would like an appointment right away. In emergencies or urgent situations, you can get appointments immediately or within 24 hours as needed. Because all doctors' offices have to set priorities by level of urgency, please be patient when it takes a little longer to get an appointment for more routine care. And please try to call well in advance to schedule complete physical exams, which require a longer appointment than usual.
Please also understand if the doctor is not ready to see your child right on time. Emergencies and urgent situations arise frequently for physicians, and even the best-planned schedules can be unavoidably disrupted as a result.
8. How does my child get dental care?
When your child enrolled in HIP, he or she was sent a Welcome Kit containing a cover letter, Member Handbook, Contract and other information about the plan. Check the back of the cover letter in Part One of your child's Welcome Kit. You'll find the name of the dentist your child was assigned at enrollment. If you want to change dentists, you can choose one from the Dental Guide section in Part Two of the Welcome Kit. Then call Healthplex at 1-800-468-9868 to tell them which dentist you have selected for your child.
The back of the cover letter also tells you what to do if your child is now receiving continuing dental care from a dentist who is not in the HIP network.
9. If I have more questions, where do I go for help?
If you have a question or concern about your
child's HIP membership, you can contact Customer Service
via e-mail and expect a response within 48 hours. Or, if you prefer
to speak directly with someone by phone, Customer Service Advocates are available Monday through Friday, 8 am to 6 pm at 1-800-HIP-TALK (1-800-447-8255).
If you have a hearing or speech impairment and use a TDD,please call
1-888-HIP-4TDD (1-888-447-4833) Monday-Friday, 8:30 am-5 pm.
Important Note: HIP has arranged for certain administrative functions to be handled by provider organizations. As a result, you may have some different contact points. Check the back of your child's HIP ID Card for any special contact information and follow the instructions on the Card.
