When you frst become a member, get to know your
PCC staff. Your PCC doctor is the main doctor you see
for care. It can be a pediatrician, family doctor, general
practitioner, internist or even someone at a clinic. Think
of this doctor and his or her offce like a second home –
your home for medical care. It’s important that you
treat your PCC doctor like your personal doctor. You
can see the PCC for care or a well visit.
So why see your PCC? Here are three good reasons:
1
It’s a one-stop shop: instead of having to fgure out
where you need to go for a problem, start with your
PCC and you may only have to make one stop.
2
You get to know and trust a provider: when
you fnd a place or even a doctor you like and
see him or her regularly, you build trust. That
can lead to both you and your doctor being
honest and working together to get you the
best care.
3
You get personalized care: if you have an allergy,
does your doctor know it? Does he or she know
if you have a family history of disease? The more
the doctor knows, the better-informed the doctor
will be in order to make the decisions that are
best for you and cover your basic needs.
Remember, if you see a doctor who is not your PCC
doctor without an OK from us, the visit may not be
covered. It all depends on what you see the doctor for.
This is explained in your Member Handbook. So be sure
to read it or call us if you have a question.
Also, you can change your PCC doctor at any time
for any reason. See your PCC doctor before you go to
another doctor. It’s the best way to get the care you need.
What Utilization
Management (UM) is
and how it affects you
UM is a part of the prior authorization process (as
described in your Member Handbook) that helps
decide if certain outpatient care, an inpatient hospital
stay or a procedure is a covered service. This means
that both CommunityConnect HealthPlan and your
PCC (or specialist) agree that the service is medically
necessary. Coverage decisions are based on:
•
•
Medical policies.
•
•
Nationally recognized clinical guidelines.
•
•
Your health benefts.
You should know that:
•
•
We make decisions based on care and services
you need and the benefts you have.
•
•
We do not reward doctors, providers or decision-
makers who work with us for not approving
requested care or services.
•
•
We do not provide fnancial incentives for those
who make UM decisions to encourage decisions
that result in less care given.
To learn more about the UM process, call us
toll-free weekdays except holidays from 8 a.m.
to 5 p.m. at 1-877-471-6656. We have a free
interpretation service at this number as well. When
you call, just ask for an interpreter in your language.
If you call before or after hours, you can leave
a private message and a member of our staff will
return your call on the next business day during the
hours above, unless you request a different time.
Any staff member who calls you about a UM issue
will give you his or her name and title and the name
of the company.
If you have hearing or speech loss and want
to reach UM, you can call the TDD/TTY line at
1-800-947-3529.
Speak another language?
¿Habla otro idioma?
Let us interpret
We can help you no matter what your preferred
language is. We have a free interpretation service.
Just call us at 1-888-279-1227 or call MedCall
at 1-877-309-4884. Ask for an interpreter in your
preferred language.
You can also ask for written materials to be read to
you over the phone in your language by an interpreter.
Just call the number above. If you have hearing or speech
loss, you can call the TTY line at 1-800-947-3529 or
the MedCall TTY at 1-800-368-4424.
Podemos traducir esto gratuitamente. Llame al
número de servicio de atención al cliente que aparece
en su tarjeta de identifcación (ID card).
What Is Quality Improvement?
Did you know we check the quality of services that
members like you receive? We call this Quality
Improvement (QI). You may ask us to send you
information about our QI program. This includes what
the program is and a report about our progress in
meeting program goals. Just call the CCH Member
Advocate Call Center at 1-888-279-1227. If you have
hearing or speech loss, call 1-800-947-3529. You also
can call 1-888-279-1227 for a paper copy.
Know your rights
We want you to know what your rights and
responsibilities are as a member of our
health plan. To read about your rights, visit
CommunityConnectHealthPlan.com. Click
Members
. Choose
Plans and Benefts
. Scroll down
to the bottom center and click
member handbook
.
You also can fnd your rights and responsibilities
listed in your paper copy of the Member Handbook,
or call us at 1-888-279-1227 to ask for a paper copy.
At home with your PCC
My Health · 7