Answers to Common Questions

Telephone Assistance

Please call our member services department at 1-888-563-2250 Monday through Friday 8:00 a.m. to 5:00 p.m. Pacific Standard Time, if you have any questions regarding:

• Choosing a physician
• Seeing a specialist
• What to do in emergency situations
• Changes in your plan coverage

We can also help when you:

• Receive a bill
• Need to file a complaint or compliment
• Need to add or term members from your contract
• Have to be hospitalized

Regardless of your questions, Western Health Advantage Member Services is here to help you.

Important information if you live outside the WHA service area

Western Health Advantage (WHA) is pleased to welcome new members who work in the health plan's service area, but who may be living on the borders or outside the county boundaries in which WHA is licensed for business. If you are one of these long-distance commuters, WHA wants you to understand that certain restrictions can apply regarding your health plan coverage. These restrictions can impact your ability to access care and more importantly, can result in your paying for services out-of-pocket.

Since your primary care physician is located within the WHA service area, you are required to receive all routine and preventive services there as well. This includes care you may require for routine illnesses such as colds, flu, headaches, minor sprains and other illnesses and injuries that are not classified as urgent or emergency care.

Urgent care is for those serious conditions, which if left untreated, could result in a life or limb threatening event. Emergency care is any care that is perceived to be life or limb threatening or when severe pain is present, and for which you should call 911 or immediately seek emergency services.

If you live outside WHA's service area, care in your residential community is strictly limited to urgent or emergency care. Misuse of urgent or emergency services for care that is classified as "routine" could result in denial of your claims. If denial occurs, you may be held financially responsible for the charges. If you have any questions or concerns about this message, please call WHA's Member Services department at 1-888-563-2250.

What if I want to change my primary care physician (PCP)?

Simply call Western Health Advantage (WHA) Member Services toll free at 1-888-563-2250 or locally at (916) 563-2250, Monday through Friday, 8:00 a.m. to 5:00 p.m. and give us the name of your new physician or you can now log onto WHA Personal Access. It provides you with "Personal Access" to your member information on the WHA website, www.westernhealth.com. By registering with your Member ID and obtaining a PIN number you can now change your PCP online (new feature). Changes are effective the first of the following month and a new I.D. card will be sent to you in both scenarios.

Who can be my primary care physician?

Primary Care Physicians (PCP) can be Family Practitioners, Internists, General Medicine, Pediatricians and, in some cases, Obstetricians and Gynecologists. Each family member can choose a different PCP from different medical groups. The PCP is responsible for coordinating all of your medical care needs. It is extremely important to get established with your physician as soon as your coverage becomes effective.

What happens if I need to see a specialist?

Your PCP will refer you when you require services from a specialist. Members can self-refer for their annual eye exam and annual well woman visits.

Is my doctor in the WHA plan?

The WHA Provider Directory lists WHA PCP's and specialists. However, we add new providers from time to time and others may leave WHA as they retire or relocate. Call Member Services to confirm whether your doctor is participating with WHA or check the Provider Directory.

Do my PCP and specialist have to be in the same WHA medical group?

No. The WHA Advantage Referral System allows patients to select a PCP in one medical group, but when referred for specialty care, patients may elect to see a specialist in any of the other WHA medical groups. This system gives the patient freedom of choice and flexibility, and eliminates the frustration experienced in other HMO plans when a patient cannot see a specialist outside of their PCP medical group. Women may also choose a participating OB/Gyn from another WHA medical group.

When will I get an I.D. card?

ID cards are mailed to members' homes within a few weeks of enrolling. New ID cards are mailed whenever a change occurs which affects the information on the card. Changes would include a new PCP, a name change, a new physician phone number, etc. A copy of your electronic enrollment confirmation or enrollment form can be used as temporary proof of coverage until your card arrives.

Will WHA cover well baby care and immunizations?

Yes, WHA will cover well baby care and immunizations at 100% from birth to two years of age. Certain groups may have a copay associated with office visits. Refer to your evidence of coverage for details.

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