Provider Network: How To Get Services
It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which IEHP DualChoice Cal MediConnect Plan (Medicare - Medicaid Plan) authorizes use of out-of-network providers.
If IEHP DualChoice is new for you, we will work with you to develop an Individualized Care Plan to address your needs. You can continue seeing the doctors you go to now for as long as your doctor(s) agrees with IEHP’s terms and rates and has no quality issues, for a period of up to 12 months for services covered by Medicare, and up to 12 months for services covered by Medi-Cal.
What are Network providers?
Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment as payment in full. We have arranged for these providers to deliver covered services to members in our plan.
All of our plan participating providers also contract us to provide covered Medi-Cal benefits.
Find a Doctor
Use the IEHP DualChoice Provider and Pharmacy Directory below to find a network provider:
What is a Primary Care Physician (PCP) and their role in your Plan?
A PCP is your Primary Care Physician. You will usually see your PCP first for most of your routine health care needs. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. This includes:
- your X-rays
- laboratory tests, therapies
- care from doctors who are specialists
- hospital admissions, and follow-up care
Primary Care Physicians (PCPs) are usually linked to certain hospitals. When you choose your PCP, remember the following:
- You must choose your PCP from your Provider and Pharmacy Directory. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP.
- Choose a PCP that is within 10 miles or 30 minutes of your home.
- The PCP you choose can only admit you to certain hospitals. Try to choose a PCP that can admit you to the hospital you want within 15 miles or 30 minutes of your home.
- Some hospitals have “hospitalists” who specialize in care for people during their hospital stay. If you are admitted to one of these hospitals, a “hospitalist” may serve as your caregiver as long as you remain in the hospital. When you are discharged from the hospital, you will return to your PCP for your health care needs.
- If you need to change your PCP for any reason, your hospital and specialist may also change. Your PCP should speak your language. However, your PCP can always use Language Line Services to get help from an interpreter, if needed.
- If you do not choose a PCP when you join IEHP DualChoice, we will choose one for you. We will send you your ID Card with your PCP’s information. Remember, you can request to change your PCP at any time.
- You can switch your Doctor (and hospital) for any reason (once per month). If your change request is received by IEHP by the 25th of the month, the change will be effective the first of the following month; if your change request is received by IEHP after the 25th of the month, the change will be effective the first day of the subsequent month (for some providers, you may need a referral from your PCP).
How to Get Care from a Specialist
You will usually see your Primary Care Physician (PCP) first for most of your routine healthcare needs such as physical check-ups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don't have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself.
What if you are outside the plan’s service area when you have an urgent need for care?
Suppose that you are temporarily outside our plan’s service area, but still in the United States. If you have an urgent need for care, you probably will not be able to find or get to one of the providers in our plan’s network. In this situation (when you are outside the service area and cannot get care from a network provider), our plan will cover urgently needed care that you get from any provider.
Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States.
Changing your Primary Care Physician (PCP)
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might leave our plan’s network of providers and you would have to find a new PCP. If this happens, you will have to switch to another provider who is part of our Plan. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services. IEHP DualChoice Member Services can assist you in finding and selecting another provider. You can change your Doctor by calling IEHP DualChoice Member Services. Please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347.
For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook.
IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
Information on this page is current as of September 30, 2016