To better help you understand those benefits that are accessed differently than your Primary Care Physician (PCP) visits, referral physician visits, and pre-scheduled hospitalization visits, here is an explanation of how you should access them.
No matter where you are, care for emergencies is covered 24 hours a day, seven days a week. If at all possible, call your PCP before seeking emergency services. However, if you feel you have a medical condition that could jeopardize your health in the absence of immediate medical attention, seek medical care.
Inside the Service Area In the case of need for emergency care inside the service area, the member should obtain emergency care services from the designated Primary Care Physician or at a participating hospital emergency department.
Outside the Service Area Coverage for emergency care outside the service area is limited to the medical screening exam and care required before the Member can, without medically harmful or injurious consequences, return to the service area or be treated by a participating physician or a participating hospital.
HealthFirst HMO will reimburse the member or the emergency department for the care received, less the applicable copayment, for both inside and outside the service area.
Your Primary Care Physician will determine the need for X-Ray and/or lab work. If determined to be necessary, your PCP will coordinate a referral for you to obtain these services at participating facilities or on-site when available.
Mental Health Benefits
HealthFirst HMO has contracted with Plan 21 to evaluate and provide mental health and chemical dependency services. If a member requires treatment for mental health or chemical dependency, precertification is required. Simply call Plan 21 at 1-800-622-7276 to obtain the necessary precertification.
Please note the benefits listed above are only a partial list of your entire benefit package. Please see detailed explanations of your benefits in the Summary of Benefits.