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Your Primary Care Physician (PCP)
Each member of Unison Health Plan must choose a Primary Care Physician (PCP) from our network. Your PCP is your personal doctor. Your PCP is trained in family medicine (general practice), internal medicine, or pediatrics. If you are pregnant, you can choose an obstetrician/ gynecologist (OB/GYN) to help coordinate care during your pregnancy.
You can reach your PCP by calling your PCP’s office. Your PCP’s name and phone number are printed on your Unison ID card. You can call your PCP 24 hours a day, seven days a week.
Your PCP is the first person you should see or talk with to get healthcare services. Your PCP is the one who:
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provides medical care
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refers you to specialists
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admits you to the hospital when necessary
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keeps your medical records.
Each family member may have his or her own PCP. We have many providers right in your community. If you want a list of them, with their addresses and telephone numbers, just call our Member Services Department and ask the representative to send you one, or click here to access a link to our search.
If you have been receiving very complex, highly specialized healthcare services over a long period of time or have a degenerative or life-threatening condition, you may be eligible to have your specialist serve as your PCP.
Your PCP or a back-up doctor approved by Unison will be available to you 24 hours a day, 7 days a week. That means that you can call your PCP after office hours when you have a health problem.
Some PCP offices may allow medical residents, nurse practitioners and physicians assistants to assist in your care.
Call your PCP if you or a family member is homebound or have other special needs. Your PCP will tell you how you can get the health care services you need and will help arrange for them.
If you cannot reach your PCP or need more help, call the Member Services Department and we will help you.
Specialists
If you have a complicated illness or condition, frequent visits to a specialist may be necessary. If you require frequent visits to a specialist, Unison Health Plan can help you coordinate your healthcare. You may see your specialist as often as needed.
In special situations, a specialist may serve as your PCP. A specialist serves as a PCP for members with very complex health care needs. If your medical condition requires a specialist to serve as your PCP, Unison Health Plan will help you find a specialist. The specialist will be able to serve as your PCP and will be available to you 24 hours a day, 7 days a week.
If you have a complicated illness or condition, please call Member Services at 1.800.895.2017 (TTY1.888.616.0021). We will help you. Member Services can also provide you with a list of specialists.
Emergency Medical Condition
An emergency medical condition is a health problem so severe, that the average person who has basic knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:
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placing the health of the person afflicted with such condition in serious jeopardy, or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy; or
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serious impairment to such person’s bodily functions; or
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serious dysfunction of any bodily organ or part of such person.
For a pregnant woman, the beginning of contractions can be considered an emergency medical condition. An emergency medical condition can result from an accident or a sudden illness and can happen at any time of the day or night. If you have an emergency illness or injury, you must act quickly. You should call 911 and ask for help or go to the nearest hospital emergency room. You do not have to call Unison or your doctor first to get permission if it is an emergency. You don’t have to worry about the cost of going to an emergency room if you think you have a medical emergency. Even if you are outside the Unison service area when you have an emergency, you are still covered by the Unison plan.
Be sure to take your Unison Member ID card. Give the name and telephone number of your PCP to the emergency room staff. That way your PCP can coordinate the care following the emergency treatment. Also, be sure that you or someone calls your PCP or the Unison Member Services Department within 24 hours after you seek emergency treatment in or out of the service area.
Here are some examples of emergencies:
If you have any of these symptoms, call 911 or have someone take you to the nearest hospital emergency room. Usually colds and sore throats are not emergencies.
After-Hours Care or Care Needed When Traveling Outside The Unison Service Area
Sometimes you may need your Primary Care Provider when the office is closed or when you are traveling outside the Unison service area. If you need urgent or non-emergent care, call your PCP’s office. You will receive directions on how to access care. There is someone to help you 24 hours a day, seven days a week. If your PCP tells you to go to the nearest emergency room, call Unison within 24 hours or as soon as possible. You may also call the 24/7 Nurse Line at 1.800.542.8630 (TTY1.888.616.0021). You can talk to the Nurse Line Representative about your medical problem and he/she will tell you what you should do and/or where you should go to get treatment.
Mental Health and Substance Abuse Services
If you need mental health and/or substance abuse services, please call Member Services at 1.800.895.2017 (TTY 1.888.616.0021). You can also find additional Unison Health Plan providers by using our online Provider Directory. Or you may self-refer directly to a Community Mental Health Center or Ohio Department of Alcohol and Drug Addiction Services (ODADAS) facility which is a Medicaid provider. Please see your Provider Directory or call Member Services for the names and telephone numbers of the facilities near you.
If you decide to use a non-Community Mental Health Center or Ohio Department of Alcohol and Drug Addiction Services (ODADAS) facility, you do not need a prior authorization for outpatient therapy. The mental health or substance abuse provider must get a prior authorization from Unison before you get other services from these providers. This can include non-emergency inpatient, intensive outpatient, outpatient ECT (Electroconvulsive Therapy), psychological testing and home health services.
Hospital Care
When you go to the hospital:
- if your hospital care is not an emergency, your Primary Care Provider (PCP) will make the plans for you to go.
- if your hospital care is an emergency, you, a family member, or a friend must tell Unison Health Plan within 24 hours or as soon as possible.
Why do you need to tell Unison Health Plan if you go to the hospital in an emergency?
Out-of-Network Services
The Unison Health Plan network includes doctors and hospitals that routinely provide most requested medical services. If necessary, your PCP can request that you receive services from a provider that is not part of the Unison Health Plan network. If the requested services are available within the Unison Health Plan network of providers, you will be required to use one of these providers. If your PCP’s request for out-of -network services is denied, you may file a grievance or request a DPW Fair Hearing. You may be responsible for payment of services provided by an out-of-network physician, if these services are not prior authorized or if the service is not covered by Unison Health Plan.
New Services or Procedures
We will evaluate any and all new technologies that are requested by your doctor for your care. Our medical directors, who consider new medical and scientific information, as well as governmental requirements, review these requests. Any medically necessary treatment, that is not considered to be experimental, will be reviewed and we will notify you and your doctor of the decision. As new services or procedures are evaluated and approved as newly covered benefits, you will be notified as a member of Unison Health Plan. We will notify you by way of our quarterly member newsletter or a special mailing.
Utilization Management
Unison’s Utilization Management (UM) decisions are made based upon medical necessity. Key points to remember are:
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our UM decision making is based solely on appropriateness of care and service.
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we do not offer any incentive to deny coverage.
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we do not offer any incentive to en-courage inappropriate utilization.
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our decisions are based on nationally accepted medical criteria, and all medical necessity denials are reviewed by physicians.
Our UM team is available from Monday through Friday, 8 a.m.-5 p.m., to assist with prior authorizations, admissions, discharges and coordination of members’ care. On-call staff is available 24 hours a day, 7 days a week for emergency prior authorization purposes.
Medical Director Availability
Our medical directors invite you to call regarding a denial, utilization issue, etc., within seven working days of the denial notification. We sometimes gain information about the patient and his/her circumstances that justifies re-consideration of the denial. If the request for reconsideration is made within seven working days, a formal grievance is not required. Participating providers can receive copies of our UM criteria. Call our UM team at 1.800.366.7304.