Health Plan Basics
When you enroll in Western Health Advantage, you must select a primary care physician (PCP) for yourself and each of your covered family members. PCP's can be practitioners of Family, Internal or General Medicine, Pediatricians and in some cases, Obstetricians and Gynecologists. Each family member can choose his/her own PCP from any of our medical groups. Your PCP is responsible for coordinating all of your medical care. It is extremely important to get established with your physician as soon as your coverage becomes effective. To locate a list of available physicians, please refer to the WHA's Online Provider Directory. You may also request a print copy by calling Member Services.
Establishing a relationship with your PCP is critical to your ongoing health care needs. Your PCP will coordinate your medical care by direct treatment or referral to a participating specialist. All non-Urgent Care or non-Emergency Care should be received from your PCP or other Participating Provider as referred by your PCP. If you have never been seen by the PCP you choose, please call his/her office before designating him/her as your PCP as some practices may be temporarily closed because they are full. If you do not designate a PCP at the time of enrollment, WHA will assign one for you.
Here are a few questions that may be useful to consider when selecting a new PCP:
- What's the most convenient location for your PCP's office--near work or near home?
- Would you prefer a male or female PCP?
- Would you like to see your PCP in a private office or in a setting that offers multiple services under one roof?
- Do you prefer to speak to your PCP in another language or have specific cultural needs?
- Referrals are a great way to find the right PCP. Can your friends or colleagues recommend a doctor?
To obtain covered services, you must see a contracted provider. You can search our Online Provider Directory that lists PCPs and specialists in the WHA network. However, we add new providers periodically and others may leave WHA as they retire or relocate. Our online, interactive Provider Directory at mywha.org/directory is a great tool to get the most up-to-date information about participating providers. You can also search for a provider by name, provider type, location of the practice(s), medical group affiliation or languages spoken.
Since your PCP coordinates all your covered care, it is important that you are completely satisfied with your relationship with him or her. If you want to choose a different PCP, you can change your PCP online by logging into your MyWHA account or by calling Member Services. WHA will issue you a new ID card confirming your new PCP's name. The effective date is the first day of the month following notification. You must wait until the effective date before seeking care from your new PCP, or the services may not be covered.
ID cards are mailed to members’ homes within a few weeks of enrolling. New ID cards are also mailed whenever a change occurs which affects the information on the card, such as a new PCP, a name change or a new medical plan. As a member, you can also access and print your ID card at mywha.org. A copy of your enrollment form or electronic enrollment confirmation can also be used as temporary proof of coverage.
Access your Western Health Advantage info straight from your smartphone. Quickly find out how to reach your primary care physician (PCP) and get a map to his or her office. Look up details about your plan, such as your copayment or your pharmacy plan. It’s a handy reference, too, for contacting the WHA Member Services Department and the 24-hour nurse advice line. Also keeps an electronic copy of IDs for you and your family. Learn more at mywha.org/digitalresources.
WHA’s Advantage Referral program allows you to see almost many specialists in our network, regardless of their medical group affiliation. While your PCP will typically refer you within his or her affiliated medical group, you are not limited to only those specialists. Refer to the Provider Directory or call WHA Member Services to ensure that a specialist is in the Advantage Referral program. Your PCP will coordinate a referral if you need to see a specialist. Members can self-refer within the network for their annual eye exam (when covered) and OB/GYN visits. Learn more at mywha.org/advantagereferral.
WHA makes routine and complex Case Management (CM) services available at no extra cost for members who qualify for them--generally, those with conditions that require a high level of coordination of care among multiple specialists and other health care providers. To learn more about our CM services or to determine if you qualify, contact WHA Member Services.
Additionally, for certain members living with chronic conditions, WHA offers Disease Management (DM) programs--also at no cost--to assist with identifying strategies to optimize their health and reach personal health goals. To learn about current DM programs and populations they serve, visit mywha.org/dm or contact WHA Member Services.
WHA has partnered with Optum to provide our members with innovative ways to lead healthy lifestyles.
Through the Optum Health Portal you have 24/7 access to an interactive decision aide tool that will guide you through making important health decisions . In addition, you have immediate access to registered nurses through the Nurse 24 private chat or by calling 877.793.3655. Learn more at mywha.org/healthsupport.
Typically, out-of-network services are not covered unless in an urgent or emergency situation. However, if you are a new member currently undergoing acute treatment with a non-participating provider, you may qualify for Continuity of Care. For more information or to obtain a Continuity of Care (CoC) Request Form, contact WHA Member Services. You may also access the CoC Form online at mywha.org.
Certain covered services require Prior Authorization from your PCP's affiliated medical group or from WHA in some cases. If Prior Authorization is not obtained, you may be liable for the payment of services or supplies. WHA and your medical group use qualified physicians and nurses to review service requests to confirm medical necessity and appropriateness. You do not need Prior Authorization for Direct Access services, which include annual eye exams and routine gynecological and obstetrical care from participating providers.
Prior Authorization is required for:
- Services from non-Participating Providers except in Urgent Care or Emergency situations
- Behavioral health services except in Urgent Care or Emergency situations
If you or another covered family member has a serious, complicated medical condition requiring multiple specialists and treatments, you may qualify for our Case Management program. If you qualify, a nurse will personally assist you to obtain the necessary pre-approvals and services you need, as well as provide health plan and community resource information to help you effectively manage your situation. Members may contact their PCP to request a referral.
Members can review their deductible balances and annual out-of pocket maximum using their secure, member-only website at mywha.org.
Important Information About Timely Access To Your Healthcare Provider On January 17, 2011, the Department of Managed Health Care's (DMHC's) Timely Access to Non-Emergency Health Care Services Regulations ("Timely Access Regulations") became effective. The regulations require health plans to ensure that health care services are provided to members in a timely manner appropriate for the nature of the member's condition consistent with good professional practice. While the Timely Access Regulations impose certain requirements on health plans, practitioners and other providers have been made aware of these requirements. Below is a table that provides appointment types and wait-time standards:
|Timely Access Regulations - Appointment Availability Standards|
|Appointment Type:||Offer the Appointment Within:|
|Non-urgent appointments with Primary Care Physicians||10 business days of request|
|Non-urgent appointments with Specialist Physicians||15 business days of request|
|Urgent care appointments that do not require prior authorization||48 hours of request|
|Urgent care appointments that require prior authorization||96 hours of request|
|Non-urgent appointments for ancillary services (for diagnosis or treatment of injury, illness or other health condition)||15 business days of request|
|Non-urgent appointments with a non-physician mental health care provider||10 business days of request|
Exceptions to the Appointment Availability Standards
Preventive Care Services and Periodic Follow Up Care: Preventive care services and periodic follow up care are not subject to the appointment availability standards. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.
Extending Appointment Waiting Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.
Advanced Access: The primary care appointment availability standard listed above may be met if the primary care physician office provides "advanced access." "Advanced access" means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician's assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day).
A member may request a second medical opinion regarding any diagnosis and/or any prescribed medical procedure. Members may choose any WHA Participating Provider of the appropriate specialty to render the opinion. All opinions performed by non-Participating Providers require Prior Authorization from WHA or its delegated medical group. All requests for second medical opinions should be directed to the member's PCP.
WHA covers you for Urgent Care and Emergency Care services wherever you are in the world. Please note that emergency room visits are not covered for non-Emergency situations.
If an Urgent Care situation arises while you are in WHA's Service Area, call your PCP. You can call your doctor at any time of the day, including evenings and weekends. Explain your condition to your PCP or the physician on call and he/she will direct your care. In the event you are not able to reach your PCP, you should go to an Urgent Care facility affiliated with your medical group.
If an Emergency situation arises whether you are in WHA's Service Area or outside of the Service Area, call "911" immediately or go directly to the nearest hospital emergency room. If you are hospitalized at a non-participating facility because of an emergency, WHA must be notified within twenty-four (24) hours or as soon as possible. If you are unable to make the call, have someone else make it for you, such as a family member, friend, or hospital staff member.
Follow-up care after an emergency room visit is not considered an Emergency situation. If you receive Emergency treatment from an emergency room physician or non-participating provider and you return for follow-up care (for example, removal of stitches or redressing a wound), you will be responsible for the cost of the service. Contact your PCP for all follow-up care.
Visit Urgent and After-Hours Care to learn more.
WHA covers you for urgent care and emergency care services wherever you are in the world. If you are hospitalized at a non-participating facility because of an emergency, WHA or your PCP must be notified within 24 hours of the emergency or as soon as possible.
Please note that emergency rooms visits are not covered for non-emergency situations. Also, call your PCP for all follow-up care for your emergency treatment. If you return to the emergency room or non-participating provider for follow-up care (for example, removal of stitches or redressing a wound), you will be responsible for the cost of service. If your emergency health problem requires a specialist, your PCP will refer you to an appropriate participating provider as needed.
In certain circumstances, members may temporarily continue care with a non-participating provider. If you are being treated by a provider who has been terminated from WHA's network, or if you are a newly enrolled member who has been receiving care from a provider not in WHA's network, you may continue care with that provider if you meet the Continuity of Care (COC) criteria explained below:
- An acute condition (care continued for the duration of the acute condition)
- A serious chronic condition due to disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure, worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration
- A pregnancy (care continued for the duration of the pregnancy and the immediate postpartum period)
- A terminal illness, an incurable or irreversible condition that has a high probability of causing death within one year
- Care of a newborn child whose age is between birth and thirty-six (36) months (care continued for a period not to exceed twelve (12) months
- Performance of surgery or other procedure that has been authorized by WHA or the medical group as part of a documented course of treatment that is to occur within one hundred eighty (180) days
If you are a newly enrolled member and you had the opportunity to enroll in a health plan with an out-of-network option, or had the option to continue with your previous health plan or provider, but instead voluntarily chose to change health plans, you are not eligible for Continuity of Care. Please contact Member Services prior to enrollment and no later than thirty (30) days from the effective date of your WHA coverage, or from the date your provider terminated with WHA to request a print copy of the COC form. You may also download an electronic copy of the COC form.
WHA will assist members with transition to other care when benefits end or during transition from pediatric care to adult care.
Transitioning Care When Benefits End
If your benefits are exhausted while you still need care and you are in a case management (CM) or disease management (DM) program, the CM or DM staff can discuss alternatives for continuing care and how to obtain care. If you’re not receiving these health care services, ask to speak to a WHA clinical resource representative who will be happy to assist you. Other alternatives such as Cobra coverage, Conversion/Individual plan, Medi-Cal, ACA Exchange coverage or community resources can be explored to meet your individual needs.
Transitioning from Pediatric to Adult Care
Generally, pediatric patients begin transition of care from a Pediatrician to a Family Practice, Internal Medicine or OB GYN Physician between the ages of 19 to 26 years. However, there are chronic conditions that may warrant a patient to continue their relationship and health care services within the pediatric setting.
WHA encourages members and their families to discuss this important transition with their individual physicians, as this decision should be based on each individual’s health care needs.
A WHA clinical resource representative is available to help should you need assistance in transitioning your health care services or have any questions. For more information, call member services and ask to speak with a Clinical Resource Nurse.
WHA encourages its practitioners to practice open physician-patient communication and to freely discuss available treatment options, including medication treatment options, with their patients regardless of the patient's benefit coverage limitations. Practitioners shall not be penalized for discussing medically necessary or appropriate care and the available options with their patients.
WHA's physician reviewers make coverage decisions related to appropriateness of care and services using available medical information about the patient and criteria that are based on recognized standards of medical practice. During these reviews, health plan benefits and individual circumstances of the patient are also considered.
Financial incentives or compensation are not linked to these decisions or to the withholding of care. If you would like to learn more about WHA's utilization management processes or receive information about the criteria or guidelines used by WHA to make care and treatment decisions, please contact WHA's member services department.
Utilization Management Criteria
Criteria primarily used by WHA’s physician reviewers to make medical necessity decisions at the health plan level include the following sources:
- MCG® (formerly Milliman Care Guidelines) – Acute, Ambulatory & Chronic Care guidelines
- UpToDate® – Evidence-based physician authored clinical decision support resource
- Hayes New Technology Assessment guidelines – Experimental guidelines
- Optum Complete Guide to Medicare Coverage Issues
Most criteria and guidelines are protected by copyright, however if a service is denied for medical necessity reasons, you will receive written rationale with excerpts or references to the criteria that was used to make the decision. You will also be provided with information on how to submit an appeal or a request for re-review of your case by another physician if you do not agree. To obtain more information about the utilization management or appeal processes, decision criteria or pharmaceutical management procedures, please contact Member Services and ask for the Medical Management department.
As a member, you and/or your dependents must live within a WHA service area* zip code. If a member or dependent no longer lives in a WHA Service Area, they will no longer be eligible for coverage through WHA. It is important to understand that you must choose a PCP from the WHA network and you are required to receive all routine and preventive services there. This includes care you may require for routine illness such as colds, flu, headaches, minor sprains and other illnesses and injuries that are not classified as urgent or emergency care.
For members with a group plan, please refer to your Evidence of Coverage/Disclosure Form (EOC/DF) and Copayment Summary(ies) for a detailed description of coverage benefits and limitations.
*For WHA's service area map, visit westernhealth.com.
If your dependent child lives outside of our service area, he or she is eligible for in-network coverage only if a full-time student. Note: Those students who reside outside the service area must obtain all routine, preventive and follow-up care from WHA network providers. When outside the service area, these students are covered only for urgent or emergency care.
Information and resources pertaining to utilization management and quality procedures are available to WHA Members, prospective members and employers through our website. At westernhealth.com/faqs , you will find information about the following topics, among others:
- Prior Authorization
- What does and doesn't require Prior Authorization?
- How does WHA make medical necessity decisions?
- Member participation in medical treatment decisions
- Second opinions
- New technology requests
- Standing referrals
- Continuity of Care
- Grievances and appeals
Western Health Advantage and our providers support your right to obtain excellent care. If you have needs with regard to your culture, language or a disability, contact our Member Services department.
If you need assistance in a language other than English (assistencia en un idioma distinto al inglés), WHA offers interpretation services, including American Sign Language. You can request these services by contacting WHA Member Services, or you can ask your doctor's office when you call for an appointment.
Spanish versions of vital plan documents are available online or through WHA Member Services. You may also contact Member Services for vital plan documents translated in your language, large text, braille, or other formats to accommodate your needs.
WHA's Member Services is happy to help you:
- Getting started with your WHA coverage.
- Choosing a PCP or learn how to see a specialist.
- Obtain and understand your benefit plan information
- Find out what to do if traveling or in and emergency situation
- Obtain interpretive services of translations of printed material
- Find out what to do if you receive a bill
- File a compliment or complaint
- Provide you with a copy of your Copayment Summary(ies) and/or EOC/DF
- Western Health Advantage and our providers support your right to obtain excellent care. If you have needs with regard to your culture, language or a disability, contact our Member Services department.
If you need assistance in a language other than English, WHA offers verbal interpretation services--simply contact WHA Member Services or let your doctor's office know when you call for an appointment. Spanish language versions of all vital plan documents are available to our membership online or through WHA Member Services.
- December 30, 2015