Questions about HIP VIP® Medicare Plan
What's the role of my Primary Care Physician?
Your Primary Care Physician (PCP) is your personal physician. He or she provides
your health care and/or refers you to specialists when you need specialty
services. It's very important for you to understand that neither HIP nor
Medicare will cover care you receive without a referral from your PCP. There
are a few exceptions, which are referred to in the answer to Question 4 below.
Look on your HIP Identification Card. Your PCP's name and phone number are
printed on the front of the card. If the name that appears is not the PCP you
selected, or if no name appears, call HIP Customer Service at 1-800-HIP-TALK
[1-877-344-7364 (TDD: 1-888-447-4833)]. To see the latest list of participating
providers, you can use the Provider
Do I call my PCP in an emergency?
Yes, unless it's a life-threatening emergency. In a life-threatening emergency,
you should call 911 and get the help you need immediately. Keep in mind that
your plan does not cover use of hospital emergency rooms for non-emergency
care, that is, for care that does not match the definition of
"life-threatening emergency" in the answer to the question below. In these non-emergency
situations, call your PCP for the help you need.
What constitutes an "emergency"?
An emergency condition is a medical or behavioral condition, the
onset of which is sudden, that manifests itself by symptoms of sufficient
severity, including severe pain, that a prudent layperson, possessing an
average knowledge of medicine and health, could reasonably expect the absence
of immediate medical attention to result in:
- Placing the health of the person afflicted with such condition in serious
jeopardy, or in the case of a behavioral condition, placing the health of such
person or others in serious jeopardy.
- Serious impairment to such person's bodily functions.
- Serious dysfunction of any bodily organ or part of such person.
- Serious disfigurement of such person.
What happens if I go to see a specialist without a referral from my PCP?
In most cases, going directly to a specialist without a referral is not covered.
However, there are a few exceptions. For example, you may schedule an
appointment with any of the following specialists who participate in the
network, without first visiting and obtaining a referral from your PCP: *
- Social Worker
- Mental Health Provider
- Women's health care specialist (OB/GYN)
- Podiatrist (for routine care)
- In addition, female members do not need a referral to access their annual
screening mammography benefit.
* Subject to the terms of your Evidence of Coverage.
Will my PCP give me a referral to any doctor in the HIP participating
Don't hesitate to ask your PCP
about certain specialists if you think that is important. Often, though, it's a
good idea to accept your PCP's judgment about referrals. Most primary care
doctors - whether they participate in a health plan like HIP or not - prefer to
give referrals to specialists they work with regularly. That means your PCP
will refer you to specialists that he or she knows and trusts. It also assures
coordination of your care when you need to see more than one doctor.
Do I have to get prior approval from HIP before getting care?
No, you do not have to obtain prior approval from HIP before
getting care. However, we'd like to take this opportunity to remind you that
the primary responsibility for your care is in the hands of your PCP. If you
receive care from your PCP, or through referral from your PCP, the PCP will get
any necessary approvals for you. (Sometimes, if you. ve already been referred
to a specialist, the specialist may secure the approval instead.) Only certain
services require prior approval:
- Non-emergent transportation (i.e., land and air ambulances).
- All inpatient hospital admissions (non-emergency).
- Ambulatory surgery (in a hospital setting or in a freestanding surgery center).
- Skilled nursing facility admissions.
- Rehabilitation care (inpatient).
- Inpatient behavioral health, alcohol or substance abuse treatment.
- Home health care (nursing, physical therapy, occupational therapy, speech
therapy and infusion therapy).
- Durable medical equipment (customized and rental).
- All non-emergent or non-urgent services provided by any non-participating
medical provider or facility, except out-of-area renal dialysis services.
- Transplant evaluation and services.
Even though your PCP will handle the request for prior approval, it's a good
idea to check with your PCP's office staff in these cases to be sure that
advance approval was obtained. (It's also a good idea to call the office of the
doctor you've been referred to for confirmation that he or she still
participates in the HIP network.)
How long should it usually take to get an appointment with a HIP
We realize that when you decide to see a doctor, you would like an appointment
right away. In emergencies or urgent situations you can get appointments
immediately or within 24 hours as needed. Because all doctors' offices have to
set priorities by level of urgency, please be patient when it takes a little
longer to get an appointment for more routine care. And please try to call well
in advance to schedule your annual complete physical exam, which requires a
longer appointment than usual.
Please also understand that your doctor may not be ready to see you exactly on
time. Emergencies and urgent situations arise frequently for physicians, and
even the best-planned schedules can be unavoidably disrupted as a result.
If I have more questions, where do I go for help?
If you have a question or concern about your HIP membership, you can
contact Customer Service via e-mail and expect a response within 48
hours. Another convenient source of information is HIP's automated Interactive
Voice Response (IVR) system. Just call 1-800-HIP-TALK (1-877-344-7364) any time
of the day or night to order HIP forms and directories, verify your eligibility
or request a new member ID Card. Or, if you prefer the option of speaking with
a Customer Service Advocate, these experts are available seven days a week,
8 am to 8 pm at
If you have a hearing or speech impairment and use a TDD, please call
1-888-HIP-4TDD (1-888-447-4833), seven days a week, 8 am to 8 pm.
Important Note: HIP has arranged for certain administrative functions
to be handled by provider organizations. As a result, you may have some
different contact points. Check the back of your HIP ID Card for any special
contact information. If the Card differs from the phone numbers given above,
follow the instructions on your Card instead.