- Participating Physician Groups (PPG)
Urgent care services are subject to the applicable county's member copayment. The plan follows Medicare guidelines for urgent care services and all benefit determinations unless the member's Evidence of Coverage (EOC) explicitly states otherwise.
Definition of Urgent Care
In accordance with federal guidelines, urgent care is defined as:
- Services provided when a member is temporarily absent from the plan's service area or, under unusual and extraordinary circumstances, provided when the member is in the service area, but the organization's provider network is temporarily unavailable or inaccessible.
- Covered services that are not defined as emergency but are medically necessary and immediately required as a result of an unforeseen illness, injury or condition, and it is not reasonable, given the circumstances, for the member to wait to obtain the needed services through the plan's provider network after the member returns to the service area or the network becomes available.
Access to Urgent and Emergency Care
When possible, urgent and emergency care must be provided by the primary care physician (PCP), the on-call designee, or contracting urgent care center. The member must be transferred to an urgent care center or hospital emergency room if medically necessary. The PCP or on-call physician designee is required to be available 24 hours a day, seven days a week. When the member is outside the service area and cannot obtain care from a network provider, the plan covers urgent and emergency care rendered by any provider at the listed urgent care copayment and emergency copayment.