Access To Care “Urgently Needed Services.” In the event of an Emergency, call 911 or go to the nearest emergency room. Refer to the “Emergency and Urgently Needed Services” section.
Receiving Health Care as a Dependent While Out of Network/Service Area Enrolled Dependents residing Out of Network/Service Area will only be covered for Emergency or Urgently Needed Services when out of the Service Area. All follow-up or Routine Care must be received in Network through the Member’s PCP.
Authorization and Denial of Services Valley Health Plan contracts with Primary Care Physicians and Plan Providers who are responsible for providing and coordinating Covered Services for its Members. Except in the event of an emergency, Urgently Needed Services, or if VHP has authorized the services in advance, you must receive all of your care from these Plan Providers. Services not received from the Member’s PCP require a referral (unless such services are eligible for self-referral as defined in this EOC). All Covered Services are provided, arranged for, or coordinated by your PCP. For Members to receive Covered Services that requires an Authorization: • a VHP PCP must initiate such a referral to a specialist on behalf of the Member; • as needed, the referral is submitted for approval or Denial; and • in the event that the referral requires Prior Authorization, VHP’s Medical Director must approve Authorization prior to a Member receiving Covered Services. If you would like more details regarding the Authorization process of your Benefit Plan, contact VHP Member Services at 1.888.421.8444 (toll-free). Members are notified of Authorizations and Denials by VHP in writing. Except for Emergency Services or Urgently Needed Services. Refer to the “Emergency and Urgently Needed Services” section. If you receive services without an Authorization, or if you receive services outside of the VHP Network, you may be responsible for the charges. If you believe that your Primary Care Physician or other VHP Provider has improperly denied a request for treatment or services, you may file a Grievance by calling Member Services 1.888.421.8444. You should file this Grievance within 30 days of the initial Denial. If the service you requested is still denied and you have followed the VHP Member Grievance process described in the “Member Grievances” section; you may contact the DMHC Consumer Help-line at 1.888.HMO.2219 (toll-free) or visit the Department’s Internet website http://www.hmohelp.ca.gov Requests involving an imminent and serious threat to your health will receive an expedited review, as may be required by the urgency of the situation. In the event that you are dissatisfied with any action or adjustment by your Plan Provider or VHP, you should follow the “Member Grievances” procedure as outlined in this EOC. In addition, you may also contact the California Department of Managed Health Care. Refer to the “Department of Managed Health Care Consumer Help-Line” section for more details.
V A L L E Y H E A LT H P L A N E V I D E N C E O F C O V E R A G E A N D D I S C L O S U R E F O R M 22
