Urgent Care
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Coverage for urgent care varies depending on whether it is received inside or outside the participating physician group's (PPG's) service area. It is covered if it is:
- Performed or referred by the member's selected primary care physician (PCP) or PPG at the office visit copayment.
- Performed by an out-of-network provider inside the PPG's service area, but only if the services are authorized at the listed urgent care copayment.
- Performed outside the PPG's service area when a member's circumstances require it at the listed urgent care copayment. Services provided by other providers are covered if the diagnosis demonstrates that the member requires urgently needed care. The PPG's service area is within a 30-mile radius of the member's PCP's office.
Follow-up care is covered only when performed by a provider affiliated with or authorized by the selected PPG.
HMO Physician or Practitioner only
The following document applies only to Physicians.
Coverage for urgent care varies depending on whether it is received inside or outside the member's service area, as defined in the member's Evidence of Coverage (EOC) or Certificate of Insurance (COI). It is covered if it is:
- Performed or referred by the member's primary care physician (PCP) at the office visit copayment.
- Performed by an out-of-network provider inside the member's service area, but only if the services are authorized and at the listed urgent care copayment.
- Performed outside the member's service area when a member's circumstances require it at the listed urgent care copayment. Services provided by other providers are covered if the diagnosis demonstrates that the member requires urgently needed care.
Follow-up care is covered only when performed by the member's PCP or authorized by the plan.