PROVIDER NETWORK

YOUR PRIMARY CARE PHYSICIAN AND OTHER DOCTORS
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Your Primary Care Physican and Other Doctors

When you sign up with your Insurer, you must choose a doctor or “primary care physician” (PCP). This is the main person you will see for most of your health care. This includes checkups, treatment for colds and flu, health concerns and health screenings. Your PCP can find and treat health problems early. He or she will have your medical records. Your PCP can see your whole health care picture. Your PCP keeps track of all of the care you get.

There are different types of doctors who are PCPs, like:

  • General Practitioners
  • Family Physicians
  • Pediatricians
  • Gynecologists/Obstetricians
  • Internists

You must choose a PCP for each insured member in your family. Your family members can have different PCPs.

If you are a woman over age 12, you can also choose a gynecologist to be your PCP. If you are pregnant, your PCP could be your obstetrician during your pregnancy. When your pregnancy ends you will go back to your regular doctor, but your gynecologist will still take care of your gynecological needs. You may choose a pediatrician or a family physician for your newborn or one will be chosen for you.

To choose your PCP, call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired). If you do not choose one, then one will be chosen for you.

A Primary Medical Group is a group of doctors that help arrange your health care services and work with your Insurer to make sure you get the care you need. Your ID card shows the name of your PCP and your Primary Medical Group number.

If you need an appointment, call your PCP. It is free to make appointments with them. It is important that you keep your appointments with your PCP. If you cannot make it for any reason, call the PCP’s office right away to let them know.

If your PCP is new for you, you should get to know him/her. Call to get an appointment as soon as you can. This is even more important if you’ve been getting care or treatment from a different doctor. We want to make sure that you keep getting the care you need. If you feel OK, you should call to get a checkup with your PCP.

Preferential Turns: The policy of requiring Network Providers to give priority in treating Enrollees from the island municipalities of Vieques and Culebra, so that they may be seen by a Provider within a reasonable time after arriving at the Provider’s office. This priority treatment is necessary because of the remote locations of these municipalities, and the greater travel time required for their residents to seek medical attention.

Before you go to your first appointment:

  1. Ask your past doctor to give you your medical records. This will not cost you anything. Bring your medical records to your new PCP at your first visit. They will help your new PCP learn about your health.  
  2. Call your PCP to schedule your appointment.
  3. Have your ID card ready when you call.
  4. Say you are a Vital Plan member and give them your ID number. 
  5. Write down your appointment date and time. If you’re a new patient, the provider may ask you to come early. Write down the time they ask you to be there.
  6. Make a list of questions you want to ask your doctor. List any health problems you have.
  7. If you need a ride to the appointment and have no other way to get there, call your Insurer or your local Municipality. They can help you get a ride.

On the day of your appointment:

  1. Bring a list of all your medicines and your questions with you so your doctor will know how to help you.
  2. Be on time for your visit. If you cannot keep your appointment, call your PCP to get a new time.
  3. Take your ID card with you. Your PCP may make a copy of it.

Most PCPs have regular office hours. Your Insurer’s Provider Directory will tell you when your doctors’ offices are open. Most Primary Medical Groups also have clinics that are open late. But, you can call your Insurer service line anytime.

You can get emergency health care any time you need it. Always carry your ID card with you. In case of an emergency, doctors will know you have Vital Plan. If you call your Insurer's Medical Advice Service Line before you go to the emergency room, you will not have to pay when you go to the emergency room.

Your Insurer's Medical Advice Service Line number is 1-844-337-3332 (toll free) or TTY 787-522-3633 (for the hearing impaired).

Emergencies are times when there could be serious danger or damage to your health if you don’t get medical care right away. 


Emergencies might be things like:

These are usually not emergencies:

  • Shortness of breath, not able to talk
  • Sore throat
  • A bad cut, broken bone, or a burn
  • Cold or flu
  • Bleeding that cannot be stopped
  • Lower back pain
  • Strong chest pain that does not go away
  • Earache
  • Strong stomach pain that doesn’t stop
  • Stomachache
  • Seizures that cause someone to pass out
  • Small, superficial, cuts
  • Not able to move your legs or arms
  • Bruise
  • A person who will not wake up
  • Headache, unless it is very bad and like you’ve never had before
  • Drug overdose
  • Arthritis

If you think you have an emergency, go to the nearest hospital Emergency Room (ER). If you can’t get to the ER, call 911.
If you need emergency care, you don’t have to get an OK from anyone before you get emergency care.

If you are not sure if it’s an emergency, call your PCP. You can call your Insurer’s Medical Advice Service Line at any time. Your PCP can help you get emergency care if you need it.

You can also call Vital Plan call center for advice. Their phone number is on the back of your ID card. You can call 24 hours a day, 7 days a week.

Additional Information, including the Provider Guidelines and Information on the structure and operations of the GHP and Physician Incentive Plans, shall be made available to Enrollees and Potential Enrollees upon request

Yes, you can change your PCP. There are many reasons why you may need to change your PCP. For example, you may want to see one whose office is closer to you. To change your PCP:

  • Find a new PCP in your Insurer’s Provider Directory.
  • Call the new PCP to make sure that they are in your Insurer’s network. Be sure to ask if they are taking new patients.
  • If the new PCP is in your Insurer’s network and taking new patients, call your Insurer at 1-844-336-3331(toll free), TTY 787-999-4411 (for the hearing impaired). and tell them you want to change your PCP.  You can also make the change by visiting your Insurer’s Service Center.

You can also change to a new Primary Medical Group if the PCP you want to see is in a different Primary Medical Group.
Most of the time, after the first 90 days of signing up with your Insurer, you can change your Primary Medical Group at any time for some reasons, like if:

  • Your PCP can’t give you the care or treatment you need because of ethical (moral) or religious reasons.
  • Your PCP can’t give you all the services you need at the same time, and not getting services at the same time is risky for your health.
  • You get bad quality care.
  • You can’t access the services you need.
  • Your PCP doesn’t have experience to take care of your health care needs.

For orientation and to make the change, call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired).

Another reason why your PCP or Primary Medical Group could change is if your PCP or Primary Medical Group stops working with your Insurer. If this happens, your Insurer will send you a letter letting you know your new PCP or Primary Medical Group. If you want to change your PCP or Primary Medical Group, call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired).

Once you make the change with your Insurer, it will take some time for the change to be effective. If you make the change in the first 5 days of a month, it will be effective in the next month. For example, if you make the change on January 5, it will be effective on February 1. But if you make the change after the first 5 days of the month, it will be effective the month after next. For example, if you make the change on January 6, it will be effective March 1.

You should keep seeing your old PCP until the change is effective. You cannot start seeing your new PCP until the effective date.

Besides your PCP, you may also need to see other doctors and health care providers, like specialists. A specialist is a doctor who gives care for a certain illness or part of the body. One kind of specialist is a cardiologist, who is a heart doctor. Another kind of specialist is an oncologist, who treats cancer. There are many kinds of specialists.

Besides specialists, you may also need to go to other healthcare professionals and healthcare facilities to get care, like laboratories, x-ray facilities, or hospitals. The doctors, other health care professionals and service facilities that work with your Insurer and your Primary Medical Group are called the Preferred Provider Network.

The other doctors, other health care professionals and service facilities that work with your Insurer are called the General Network. When you sign up with your Insurer, they will mail you a Provider Directory for the Preferred Provider Network and the General Network. These lists are also available here or your Primary Medical Group and your Insurer’s Service Centers also have a copy of the lists. 

For more information about how Vital Plan works if you have Medicare, look here.

Preferred Provider Network

The doctors, other health care professionals and services facilities who work with your Primary Medical Group are called the Preferred Provider Network.
There are benefits to seeing the doctors, other health care professionals and service facilities in the Preferred Provider Network:

  • You can visit any of the doctors and service facilities in the Preferred Provider Network for free.
  • If you visit the doctors, healthcare professionals and service facilities in your Preferred Provider Network, you don’t need to go to your PCP first to get a referral. 
  • If you get any of the following services within the Preferred Provider Network, you don’t need your PCP to sign off:
  • Prescription medicine
  • Laboratory tests
  • X-rays

To get more information about your Preferred Provider Network, you can:

  • Call your Insurer at 1-844-336-333 (toll free), TTY 787-999-4411 (for the hearing impaired).
  • Call Vital Plan call center at 1-800-981-2737.
  • Go to your Insurer’s Service Centers.
  • Call your Primary Medical Group.

General Network

The general network is the health care professionals and services facilities that work with your Insurer and that support the Primary Medical Groups. If the doctor or provider you need to see isn’t in your Preferred Provider Network, they might be in your Insurer’s General Network. You can see any doctor or provider in your Insurer’s General Network as long as you go to your PCP first to get a referral. If you need a referral, your PCP must give you one during your visit or within 24 hours after you ask for one.
Your PCP will coordinate your visits to doctors or providers in the General Network.

You might need to pay money for these visits. Look at Part 4 of this guide for more information about payments.
If you get any of the following by a provider in the General Network, your PCP will have to sign off:

  • Prescription medicine
  • Laboratory tests
  • X-rays

Out-of-Network

A doctor or other provider who does not work with your Insurer is called an Out-of-Network provider. If you need to see a doctor or other provider who is out-of-network, your PCP must get an OK from your Insurer first. This OK is called a prior authorization. Your Insurer must give the prior authorization within 72 hours of getting the request. If you need the prior authorization faster because of your health care needs, your Insurer must give the prior authorization within 24 hours.

If you need services from an out-of-network community health clinic, you will first need a referral from your PCP. You can get care at an out-of-network community health clinic for free.

If you feel that your Insurer or your doctors are not following these rules, you can call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired) and tell them that you need to make a complaint. You can also call the Patient Advocate Office at 1-800-981-0031 or ASES at 1-800-981-2737.

If you don’t have a way to get to your health care visits, your Insurer and your Municipality can help with transportation. Each Municipality has some ways to help you get to your visits. Call your Insurer at 1-844-336-3331(toll free), TTY 787-999-4411 (for the hearing impaired)  or call your local Municipality for help.

Your Insurer and some providers also offer transportation for some members through care management. If you need the help of a care manager and you do not have one, call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired) See here for more information on care management.

 

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