Primary Care Physician Selection & Specialty Care
Your PCP is responsible for coordinating your medical care by providing direct treatment to you or by making referrals to network specialty providers when needed. To ensure coverage, non-urgent or non-emergency care should be received from your PCP or another network provider.
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.
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.
To obtain covered services, 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 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.
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.
WHA’s Advantage Referral program allows you to 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 and OB/GYN visits. Learn more at mywha.org/advantagereferral.
No, your PCP and specialist do not have to be in the same medical group. WHA's Advantage Referral system allows more choices. You can select a PCP in one medical group, but when referred for specialty care, you may see a participating specialist in any other WHA medical group. However, not all specialists are in Advantage Referral program. To identify those physicians who do not participate, check the online provider directory, or call member services for current status.
As a member of WHA you will receive routine care from your PCP. In most cases, specialty care is also provided by WHA network physicians. Your doctor, medical group, and in some cases, WHA, will decide if you should receive specialty services from a non-network physician based on your individual healthcare needs. To see a non-network physician you must always get pre-approval to ensure coverage, except in emergency situations.
Routine care is treatment of conditions not considered to be an emergency or urgent. Examples include getting immunizations or an annual physical examination.