For Members of HIPaccess I and HIPaccess II

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 difference between HIPaccess I and HIPaccess II?

HIPaccess I includes only HMO benefits. HMO benefits provide coverage for medically necessary care that is provided by your HIP participating PCP or other HIP participating providers.

HIPaccess II includes both HMO and POS benefits. In addition to the HMO benefits described above, HIPaccess II members have access to POS benefits that provide coverage for medically necessary care provided by non-participating providers.

Please refer to your Schedule of Benefits and Certificate of Coverage to find out if you have HIPaccess I or HIPaccess II coverage.

Important Note: If you are a HIPaccess II member and use your POS benefits, you will be responsible for the deductible and coinsurance indicated in your Schedule of Benefits. HIP will provide reimbursement based on the non-participating provider's actual charge or HIP's reasonable and customary charge, whichever is less. You will be responsible for any charges above the amount paid by HIP.

2. What's the role of my Primary Care Physician?

Your Primary Care Physician (PCP) is your personal physician. For well-coordinated and directed care, you will want to have your PCP provide your health care or refer you to specialists when you need specialty services. Getting care through your PCP also helps assure that a physician who knows any health problems you may have coordinates your care.

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).

3. Do I need a referral from my PCP to see a specialist?

No. If you are a HIPaccess I member, you can see any HIP participating specialist to receive specialty care without a referral from your PCP.

If you are a HIPaccess II member, you can also see any HIP participating specialist without a referral from your PCP. Additionally, you have the option of using your POS benefits. You can then visit a non-participating provider subject to the cost sharing provisions indicated in response to Question #1 above.

4. 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 suffer serious harm to body parts, body functions or serious disfigurement will occur 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.

5. What if I need emergency care?

In an emergency (as just defined), call 911 or go directly to a hospital emergency room to secure immediate assistance.

Your plan gives you the peace of mind that comes from knowing you are covered for emergency care worldwide. 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 a life-threatening emergency given in response to Question #4 above.

If you seek care through an emergency room or a non-participating provider before calling HIP, be sure that you or someone on your behalf notifies your PCP or HIP within 48 hours, or as soon as reasonably possible after you have obtained your care.

6. What if I need urgent but non-emergency care?

Just call or visit your PCP or any HIP participating specialist. You should know that all PCPs have telephone coverage 24 hours a day, 7 days a week, so you can reach your PCP or a covering primary care doctor at any time.

If you are a HIPaccess II member, you also have the option of using your POS benefits. You can then visit a non-participating provider subject to the cost sharing provisions indicated in response to Question #1 above.

7. 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 health 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 within the HIP network.

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.

8. Do I have to get approval from HIP before getting care?

You are only required to get approval from HIP before receiving certain kinds of medical care. That care is defined as:

• 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 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).
• Outpatient cardiac and pulmonary rehabilitation.
• Outpatient diagnostic radiology services.
• Transplant evaluation and services.
• Hospice care.

If the services are provided by or arranged through a HIP participating physician, he or she may obtain approval on your behalf. But it is still your responsibility to make sure that notice was given and prior approval was obtained. Check with the doctor's office staff to confirm.

If you are a HIPaccess II member, you have the option of using your POS benefits. You can then receive services from a non-participating provider. If you choose to receive care from a non-participating provider, it is your responsibility to call HIP and request written approval for the requested services. Your benefits will also be subject to the cost sharing provisions indicated in response to Question #1 above.

9. 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 right on time. Emergencies and urgent situations arise frequently for physicians, and even the best-planned schedules can be unavoidably disrupted as a result.

10. 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 by clicking on the "Contact Us" bar at the top of this page and sending us an email. You can expect a response within 48 hours.

You can also take advantage of our Interactive Voice Response (IVR) system 24 hours a day/7days a week by calling 1-800-HIP-TALK (1-800-447-8255). Our IVR system allows you to conduct a number of transactions, including making automated HIP ID Card requests.

If you prefer to speak directly with a Customer Service Advocate, just call 1-800-HIP-TALK Monday through Friday, 8 am to 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 need to contact a provider organization instead of HIP. Check the back of your HIP ID Card for any special contact information.

Back to Top