Your Primary Care Physician (PCP) is the person to call whenever you need health
care. As a member of Central Health Medicare Plan, you will need to select a PCP
within our network. Not only will your PCP treat you for illness and injuries, but
your doctor will also provide routine and preventive care, and assist you with making
important medical decisions to see specialists or other services.
In addition, your PCP has referral relationships with Central Health Medicare Plan
contracted providers including physician specialists, skilled nursing facilities,
durable medical equipment providers and other selected providers.
You have the ability to change your PCP at anytime. If you are not happy with your
doctor for any reason and want to choose a new PCP, you may always select another
physician.
There may come a time when you need medical care only a specialist can provide.
Whether you need to see a podiatrist, audiologist, cardiologist or another type
of specialist, you want to be sure your care is covered.
In general, you must receive a referral from your PCP before you are covered to
see a specialist. During your office visit, your PCP will evaluate your condition
and, if necessary, refer you to a specialist in the Central Health Medicare Plan
network.
By obtaining a PCP referral, you will pay only an office visit co-payment for your
visit to the specialist. In most cases, if you don’t have a PCP referral to see
a specialist, your visit will not be covered.
Utilization Review
Central Health Medicare Plan reviews the care given to our members to ensure that
services are being provided, or utilized, in the best possible manner.
In accordance with National Committee on Quality Assurance (NCQA) standards, employees
of Central Health Medicare Plan who make or supervise utilization-related decisions
base these decisions only on the clinical appropriateness of care and service. Central
Health Medicare Plan does not specifically reward practitioners or other individuals
conducting utilization review for issuing denials of coverage or service. In addition,
there are no financial incentives for Utilization Management decision makers, and
Central Health Medicare Plan does not encourage decisions that result in underutilization.