When Are Out-Of-Plan Providers Part of the Plan?
Posted on June 8, 2010
Health New England (HNE) is a Health Maintenance Organization (HMO). As an HMO we require that you get your care from specific doctors, hospitals, and other healthcare providers that contract with the plan. We call these providers “In-Plan” providers or network providers. Your primary care provider (PCP) is your main point of contact for your healthcare.
Your primary care provider (PCP):
- Provides your care
- Arranges for services with in-plan providers
- Identifies the appropriate provider outside of the network, if the service is not offered in HNE’s network.
HNE does not require a referral for most visits within the HNE provider network. You can select and arrange for services with in-plan providers directly. For example, if you need to see a specialist, you can look in the HNE provider directory, choose the specialist and arrange your appointment. Please keep in mind that the services you receive must be medically necessary, and certain services and procedures require prior authorization (PA). If you are unsure of what services require a PA, please call Member Services.
While HNE in-plan providers can provide most healthcare services, there are times when you may require care that is not available in the HNE network. Your doctor, PCP, or specialist can submit a prior authorization to HNE for you to see an out-of-plan provider. If you have not yet seen an in-plan specialist, and there is one in the HNE network, you will be redirected to do so. HNE’s network offers a variety of specialists and specialty clinics. Our experienced health services team can assist you in locating a specialist that meets your needs.
In addition to the HNE Provider network, HNE has a preferred provider network outside of the service area. These providers meet HNE’s requirements for experience and quality. If your in-plan specialist is referring you to an out-of-plan provider that is not in our preferred provider network, we may redirect you to a preferred provider in the same specialty. A good example is our transplant network. Our selection of transplant providers is based on outcome studies for quality and survival rates.
It is important to all of us at HNE that you get the right care at the right time and in the right setting.
If you have questions or concerns regarding the availability of specialists in the HNE network, give us a call. We are here to help. Call HNE Member Services at 413.787.4004, or toll-free at 800.310.2835. TTY/TDD users should call 800.439.2370. A representative is available to speak with you from 8 a.m. to 8 p.m., seven days a week.
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