For Members of HIP Prime®, HIP HMO and HIP HMO Direct
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 Primary Care Physician?
Your Primary Care Physician (PCP) is your personal physician. He or she provides health care and/or refers you to specialists when you need specialty services. It’s very important for you to understand that your plan usually will not cover care you receive without a referral from your PCP. There are a few exceptions, which are referred to in the answer to Question 4 below.
Look on your HIP Identification Card. Your PCP's name and phone number are printed on the front of the card. If the name that appears is not the PCP you selected, or if no name appears, you can select or change your PCP online. Begin by doing a Provider Search. Then, Log In and follow the instructions for selecting or changing your 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 PCP in an emergency?
Yes, unless it’s a life-threatening emergency. In a life-threatening emergency, you should call 911 and get the help you need immediately. In non-emergency situations, call your PCP for the help you need. Keep in mind that your plan does not cover use of hospital emergency rooms for non-emergency care — that is, for care that does not match the definition of "life-threatening emergency" in 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 makes a person with an average knowledge of health fear that you or someone 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.
- When you feel like you might hurt yourself or others.
- If you are pregnant and have pain, bleeding, fever or vomiting.
Examples of non-emergencies are colds, sore throat, upset stomach, minor cuts and bruises or strained muscles.
4. What happens if I go to see a specialist without a referral from my PCP?
In most cases, going directly to a specialist without a referral is not covered. There are a few exceptions. For example, you do not need a referral from your PCP for the following services from participating providers.*
- Chiropractic treatment.
- Primary and preventive care from your PCP.
- Primary and preventive OB/GYN care, including mammography and cervical screenings.
- Outpatient treatment of mental illness.
- Refractive eye exams from an optometrist.
* Subject to the terms of your Contract or Certificate of Coverage.
5. Will my PCP provide a referral to any doctor in the HIP participating network?
You can expect your 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 your PCP belongs. The exception is when the kind of care you need 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 you.
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 best interest. When the PCP coordinates all your care, you are protected against such problems as conflicting medications or duplicate procedures. These kinds of problems can occur when you are referring yourself to more than one physician.
So most HIP members 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 to see, check with that physician's office to find a participating PCP with whom this specialist regularly works. Then select the recommended PCP.
6. Do I have to get prior approval from HIP before getting care?
No, you do not have to obtain prior approval from HIP before getting care. We’d like to take this opportunity to remind you that the primary responsibility for your care is in the hands of your PCP. If you receive care from your PCP, or through referral from your PCP, the PCP will get any necessary approvals for you. (Sometimes, if you’ve 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).
- Air ambulance.
- Non-emergency land ambulances.
- Home health care (nursing, physical therapy, occupational therapy, speech therapy and infusion therapy).
- Durable medical equipment (DME).
- Transplant evaluation and services.
- Hospice care.
- Outpatient diagnostic radiology services.
- Outpatient cardiac and pulmonary rehabilitation.
- All services provided by any non-participating provider/facility, except dialysis.
Even though your PCP will handle the request for prior approval, it’s a good idea to check with your PCP’s office staff in these cases to be sure that advance approval was obtained. (It’s also a good idea to call the office of the doctor you’ve 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 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 your annual complete physical exam, which requires a longer appointment than usual.
Please also understand that your doctor may not be ready to see you exactly on time. Emergencies and urgent situations arise frequently for physicians, and even the best-planned schedules can be unavoidably disrupted as a result.
8. If I have more questions, where do I go for help?
If you have a question or concern about your HIP membership, you can contact Customer Service via e-mail and expect a response within 48 hours. Or, if you prefer to speak directly to someone by phone, Customer Service Advocates are available Monday-Friday, 8 am-6 pm. 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 HIP ID Card for any special contact information and follow the instructions on your Card.
