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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.
Specialist as a PCP
If you have a very complicated illness or condition, you may be able to have a specialist be your PCP. Call the Special Needs Unit (SNU) toll free at 1.877.844.8844. We will tell you if you qualify and how to obtain a specialist as a PCP. If you would like a directory of specialists, call the Unison Health Plan Member Services Department. You may also click here to view our provider network online.
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.
Urgent Health Care
An urgent health care condition is an illness, injury or condition that is not life threatening but that should be treated within a twenty-four (24) hour period and, if left untreated, could quickly become a crisis or an Emergency Medical Condition. If you have an urgent health care condition, call your PCP first. Your PCP will know what is best for you. Even if you are out of town, call your PCP first and s/he will tell you how to get care.
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.