When you sign up with Plan de Salud Menonita (PSM) you must choose a doctor or “Primary care Physician” (PCP). This is the main person you will see for most of your health care. This includes checkups, treatment for colds and flu, health concerns and health screenings. Your PCP can find and treat health problems early. He or she will have your medical records. Your PCP can see your whole health care picture. Your PCP keeps track of all the care you get.
There are different types of doctors who are PCPs, like:
• General Practitioners
• Family Physicians
If you do not choose a PCP, then one will be chosen for you.
You must choose a PCP for each insured member in your family. Your family members can have different PCPs.
If you are a woman over age 12, you can also choose a gynecologist to be your PCP. If you are pregnant, your PCP could be your obstetrician during your pregnancy. When your pregnancy ends you will go back to your regular doctor (PCP), but your gynecologist will still take care of your gynecological needs.
You may choose a pediatrician or a family physician for your newborn. If you do not make a selection, one will be chosen for you.
Also your PCP may be part of a Primary Medical Group (PMG). A Primary Medical Group is a group of doctors that help arrange your health care services and work with Plan de Salud Menonita to make sure you get the care you need. Your ID Card shows the name of your PCP and your Primary Medical Group number.
How can I see my PCP?
If you need an appointment, call your Primary Care Physician (PCP). It is free to make appointments with them. It is important that you keep your appointments with your PCP. If you cannot make it for any reason, call the PCP’s office right away to let them know.
If your PCP is new for you, you should get to know him/her. Call to get an appointment as soon as you can. This is even more important if you’ve been getting care or treatment from a different doctor. We want to make sure that you keep getting the care you need. If you need help getting an appointment, call the PSM Beneficiary Service Line at 1-866-600-4753 or 1-844-726-3345 TTY (hearing impaired).
Before you go to your first appointment:
- Ask your past doctor to give you your medical records. It’s your right! This will not cost you anything.
- Call your PCP to schedule your appointment.
- Have your ID Card ready when you call.
- Say you’re a Vital beneficiary with Plan de Salud Menonita.
- Give them your ID number.
- Write down your appointment date and time. If you’re a new patient, the provider may ask you to come early. Write down the time they ask you to be there.
- Make a list of questions you want to ask your doctor. List any health problems you have.
- If you need a ride to the appointment and have no other way to get there, call your Insurer or your local Municipality. They can help you get a ride.
On the day of your appointment:
- Bring your medical records to your new PCP at your first visit. They will help your new PCP learn about your health.
- Bring a list of all your medicines and your questions with you so your doctor will know how to help you.
- Take your ID card with you. Your PCP may make a copy of it.
- Be on time for your visit.
- If you cannot keep your appointment, call your PCP to get a new time.
Can I change my PCP?
Yes, you can change your Primary Care Physician (PCP). There are many reasons why you may need to change your PCP. For example, you may want to see one whose office is closer to you. To change your PCP:
- Find a new PCP in the PSM Provider Directory.
- Call the new PCP to make sure that they are in the Plan de Salud Menonita (PSM) network.
- Be sure to ask if the new PCP is taking new patients.
- For orientation and to make the change, call the PSM Beneficiary Service Line at 1-866-600-4753 (toll free) or 1-844-726-3345 TTY (Hearing impaired). The phone call is free.
You can also change to a new Primary Medical Group (PMG) if the PCP you want to see is in a different group.
Most of the time, after the first 90 days of signing up with PSM, you can change your Primary Medical Group at any time for some reasons, like if:
- Your PCP can’t give you the care or treatment you need because of ethical (moral) or religious reasons.
- Your PCP can’t give you all the services you need at the same time, and not getting services at the same time is risky for your health.
- You get bad quality care.
- You can’t access the services you need.
- Your PCP doesn’t have experience to take care of your health care needs.
Another reason why your PCP or Primary Medical Group could change is if they stop working with your PSM. If this happens, PSM will send you a letter letting you know your new PCP or Primary Medical Group.
What happens after I ask for the change?
Once you make the change with PSM, it will take some time for the change to be effective.
If you make the change in the first 5 days of a month, it will be effective in the next month. For example, if you make the change on January 5, it will be effective on February 1.
But if you make the change after the first 5 days of the month, it will be effective the month after next. For example, if you make the change on January 6, it will be effective March 1.
You should keep seeing your old PCP until the change is effective. You cannot start seeing your new PCP until the effective date.
What about other doctors or providers I need to see?
Besides your PCP, you may also need to see other doctors and health care providers, like specialists. A specialist is a doctor who gives care for a certain illness or part of the body. One kind of specialist is a cardiologist, who is a heart doctor. Another kind of specialist is an oncologist, who treats cancer. There are many kinds of specialists.
Besides specialists, you may also need to go to other healthcare professionals and healthcare facilities to get care, like:
- x-ray facilities
- or hospitals
The doctors, other health care professionals and service facilities that work with Plan de Salud Menonita, and your Primary Medical Group are called the Preferred Provider Network.
The other doctors, other health care professionals and service facilities that work with your Insurer are called the General Network. Click here for a complete list of PSM Providers.
Preferred Provider Network
There are benefits to seeing the doctors, other health care professionals and service facilities in the PSM Preferred Provider Network:
- You can visit any of the doctors and service facilities in the Preferred Provider Network for free.
- You don’t need to go to your PCP first to get a referral.
- If you get any of the following services within the Preferred Provider Network, you don’t need your PCP to sign off:
- Prescription medicine
- Laboratory tests
To get more information about your Preferred Provider Network, you can:
The General Network is the health care professionals and services facilities that work with PSM and that support the Primary Medical Groups.
If the doctor or provider you need to see isn’t in your Preferred Provider Network, they might be in our General Network. You can see any doctor or provider in the General Network as long as you go to your PCP first to get a referral. If you need a referral, your PCP must give you one during your visit or within 24 hours after you ask for one.
Your PCP will coordinate your visits to doctors or providers in the General Network.
You might need to pay money for these visits. Click here for more information about payments.
If you get any of the following by a provider in the General Network, your PCP will have to sign off:
- Prescription medicine
- Laboratory tests
A doctor or other provider who does not work with PSM is called an Out-of-Network provider.
If you need to see a doctor or other provider who is Out-of-Network, your PCP must get an OK from Plan de Salud Menonita first. This OK is called a prior authorization. PSM will reply to the prior authorization within 72 hours of getting the request. If you need the prior authorization faster because of your health care needs, the PCP must inform PSM. This reply to the prior authorization must be given within 24 hours.
If you need services from an Out-of-Network community health clinic, you will first need a referral from your PCP. You can get care at an Out-of-network community health clinic for free.
If you have any questions or feel that your Insurer or your doctors are not following these rules, you can call the PSM Beneficiary Service Line at 1-866-600-4753 or 1-844-726-3345 TTY (hearing impaired) and tell them that you need to make a complaint. You can also call the Patient Advocate Office at 1-800-981-0031 or ASES at 1-800-981-2737. The phone calls are free.