What is the role of my Primary Care Physician (PCP)?
A primary care physician is usually a doctor in general practice, family practice, internal medicine or pediatrics. Your PCP is your personal doctor, and can coordinate all of your care for you. If you haven't seen your PCP or personal physician, set up an appointment for a routine physical. This will allow you and your doctor to get to know each other. Be sure to tell your doctor all of your relevant medical history so that he or she can manage your care appropriately.
How do I select a Primary Care Physician?
To select a Primary Care Physician who participates in BlueCross BlueShield's provider network, please refer to your Provider Directory or search for a provider online by clicking here.
What if I am out of my home service area and need medical care?
Our out-of-area program covers you for urgent care when you are away from home through BlueCard®, a national network of BlueCross and BlueShield HMOs.
Urgent care must be coordinated by your PCP before you obtain services. If your PCP recommends treatment, call 1-800-810-2583 to locate a participating Blue provider.
What if I or one of my dependents will be living outside of the Western New York area?
If you (or a covered dependent) will be temporarily residing outside the Western New York area, in a participating location, for at least 90 days, you may be eligible to become a Guest Member at a BlueCross and BlueShield Association-affiliated HMO. Under the Away From Home Care® program's Guest Membership benefit you retain your coverage under BlueCross BlueShield of Western New York.
With our Away From Home Care® program's Guest Membership benefit, you can join another HMO and receive the full range of benefits offered by the HMO in that area.
Guest memberships can be used for students away at school, extended business trips, families living apart or long-term travel. Residency eligibility requirements must be met for any long-term traveler requesting Guest Membership for one year or more.
When you return to the BlueCross BlueShield of Western New York service area, you will use your primary care physician and receive your BlueCross BlueShield of Western New York benefits. For more information and to verify that this benefit is available to you, contact Customer Service.
What if I need emergency care?
If you have a medical situation or a problem that is life or limb threatening, call 911 or go the nearest emergency room immediately.When to go to the ER:
- Severe vaginal bleeding during pregnancy
- Severe asthma attack
- Broken bone
- Severe stomach pain
- Chest pain
- Severe burns
- Head injury resulting in a loss of consciousness
- Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
- Sudden confusion, trouble speaking or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance
- Sudden severe headache with no known cause
What if I need medical attention and it isn't an emergency?
Medical problems that require prompt attention, but are not life threatening (i.e., earache, rash, etc.) are considered urgent or non-emergent. These conditions may include:
- Cold or flu
- Sore throat
- Burning/frequency of urination
- Skin rash
- Pink eye
- Body lice/worms
If you have any of these conditions, call your PCP. Your PCP is available 24 hours a day, seven days a week. If your doctor is not available, another physician will be covering and can help you.
Do I need a referral to see a specialist?
A referral is the recommendation by a physician and/or health plan for a member to receive care from a different physician or facility. Most members do not need a referral from a PCP to see a specialist. If you and your PCP agree that you need to see a specialist, you can select one from our network and just pay your specialist copay.
How do I determine if I need a referral?
- Your ID card should indicate the word "referral".
- Members of Senior Blue, Child Health Plus, Healthy NY, Family Health Plus and Medicaid HMO still require a referral.
- Check with your employer or Customer Service.
Are there any services that still require referrals?
Mental health and chemical dependency services still require a call to our Behavioral Health service at 1-877-837-0814 to coordinate care. You or your PCP may place this call.
Can my current specialist refer me to another specialist?
In most cases, your specialist must contact your PCP to request a referral to another specialist. We recommend that you confirm with your PCP that he or she will request the referral. In a few cases, a referred specialist may request a referral directly from Community Blue for the following durable medical equipment (DME); prosthetic or orthotic appliances (if covered by rider); and physical, speech or occupational therapy.
Can I get a referral to a nonparticipating provider?
Only if we have determined that there is not a participating network provider that can treat your illness or condition. Your PCP must request prior approval for this type of out-of-network referral and needs to provide medical information to explain why the services of a on participating provider are necessary to treat your illness or condition. If prior approval is granted, services will be paid at the in-network benefit level.
What benefits are provided by Timothy's Law?
Timothy's Law requires health policies to include coverage for the diagnosis and treatment of mental, nervous or emotional disorders for up to 30 days of inpatient care and 20 days of outpatient care in a calendar year. Any deductible, copayments or coinsurance applied to the “Timothy's Law” benefits can be no greater than those applied to other benefits under your contract. Most members' contracts already include coverage for 30 days inpatient/20 days outpatient care; the change you may notice is in your out-of-pocket cost for these benefits, which may change to comply with the law.
Based on whether your employer is a “large group” or “small group” employer will determine whether your benefits also include coverage for the treatment of biologically-based conditions, such as schizophrenia/psychotic disorder, major depression, bipolar disorder, delusional disorders, panic disorder, obsessive compulsive disorder, bulimia and anorexia.
- If you are covered under a policy or contract issued to a large employer group (the employer has more than 50 employees eligible for health coverage), the group must provide these benefits.
- If your employer is a small group employer (50 or fewer eligible employees), your employer may choose to provide these benefits.
How do I know if my health plan includes coverage for Timothy's Law benefits?
Timothy's Law applies to most health insurance policies provided through employer groups. Excluded from this mandate are: Medicare Advantage, Healthy NY, Family Health Plus, Child Health Plus, Medicaid, Direct Pay, Dental and Administrative Services Only (ASO) accounts.
What is Prior Authorization?
Prior authorization means that certain services or medications are subject to preapproval by BlueCross BlueShield to be eligible for coverage under your health plan. We review medical information provided by your health care provider to determine if clinical guidelines have been met and that the service or medication is being used appropriately. Prescription drugs which require prior authorization are noted on our Medication Guide as such, and most injectable products require prior authorization.
I was told I needed prior authorization to obtain a service. What's the difference between prior authorization and a referral?
Prior authorization is the process of obtaining coverage approval from BlueCross BlueShield for a service or medication. Without prior authorization, the service or medication is not covered under your health-plan benefits. Your healthcare provider is responsible for obtaining the prior authorization when required. A referral is the recommendation by a healthcare provider or a health plan for a member to receive care from a different provider or facility.
How do I find out if a prescription drug requires prior authorization?
Using our Medication Guide . Your can determine whether or not your medication requires a prior authorization. This can be done by following the key at the bottom of each page where it indicates that a drug with the "" symbol next to it requires a prior authorization.
How does my provider obtain prior authorization?
Your health care provider needs to complete and fax a Prior Authorization Request form to us. We have provided copies of this form to our providers' offices, or one can be obtained by calling the customers service number listed on the back of your identification card.
How long does it take to get prior authorization?
Decisions for requests are typically made within 1-3 business days and communicated to your provider within 3 business days of the date your provider submits the prior authorization request. If, however, additional medical information is required from the provider in order to make a decision, it may take additional time for us to respond to the provider's request.
What if the medication or service the provider requested is denied?
When a request is denied, alternative treatment options which are covered under the benefit plan are suggested to the provider. Each request is reviewed individually and decisions are made based on medically sound clinical criteria developed and/or approved by one of our physician committees.
If the prior authorization request for a specific medication is denied, the drug is considered a non-covered benefit. It is not available as a third-tier medication. You have the right to appeal denials and your appeal rights will be contained in the denial letter that you and your provider will receive.