Going to the Doctor

What is a Primary Care Practitioner (PCP)?
A Primary Care Practitioner (PCP) is a participating provider who practices internal medicine, family practice, general practice, pediatrics, or obstetrics and gynecology. Aspirus Health Plan promotes building relationships between our members and their PCP, because we value personal, coordinated care.

Do I need a PCP?
Aspirus Health Plan encourages members to select a PCP to coordinate overall medical care. You may already have a relationship with a participating PCP for your health care. If so, you can designate your PCP on your enrollment form. Otherwise, you may choose a PCP for yourself and each family member at the time of enrollment. You can change your PCP at any time. If you choose to do so, please call the number located on the back of your ID card.

Relationship with Your PCP
We encourage you to develop a relationship with your primary care practitioner (PCP) that is ongoing over time, during periods of illness and health. When your PCP knows you as a whole person, he or she can understand your specific needs for health care.

Advantages
Developing a relationship with your provider may reduce the risk of unnecessary testing and the potential for medical errors.

Seeing Other Providers
Patients may need to seek care from specialists or behavioral health care providers. In these situations, it is important an accurate transfer of medical information occur between your primary care practitioner and the medical or behavioral health specialist. Feel free to call the number on the back of your ID card if you have any questions about medical record transfers.

Active Involvement
A relationship with your primary care practitioner is not a substitute for active involvement in your own care, especially if you see more than one health care provider. If you received care from medical or behavioral health specialists, be sure to share that information with your primary care practitioner. Knowing what problems you have had and which medications you take will help your health care provider give you safe, quality medical care.

In-network vs. out-of-network providers
An in-network provider is a provider who has contracted with Aspirus Health Plan to provide services to our members at negotiated rates. An out-of-network provider is one who has not contracted with Aspirus Health Plan. Typically, if you visit a physician or other provider within the network, the amount you will be responsible for paying will be less than if you receive the same service with an out-of-network provider. Though there are some exceptions, in many cases Aspirus Health Plan will either pay less, or not pay anything, for services you receive from out-of-network providers. As a rule, HMO and POS health plans make use of provider networks.

What if my PCP or specialist leaves my network?
In the event your PCP or specialist goes out-of-network, there are certain circumstances that allow you to continue to receive care from that provider. Please refer to your Certificate of Coverage or Individual Policy for further details on how continuity of care may apply.

How can I get an estimate of my out-of-pocket expenses?
At the written request of our members, Aspirus Health Plan will provide a good faith estimate of the reimbursement that Aspirus Health Plan expects to pay and the member’s responsibility (out-of-pocket costs) for a specific health care service being considered. An estimate is different from a prior authorization. Receiving an estimate does not mean a prior authorization request has been approved. When prior authorization is required, you must obtain a prior authorization approval.

Please be aware that any estimate is a verification of benefits and not a guarantee of payment. Aspirus Health Plan pays according to our contract with you and takes into account all information received at the time a claim is submitted. Payment is based on the terms, conditions, and provisions of the policy and is subject to the rates that are in effect at the time the service is performed. Terms and conditions that may affect payment include, but are not limited to:

  • Requirement for medical necessity
  • Prior authorization
  • Exclusion for work-related injuries
  • Provider network affiliations
  • Price adjustments due to negotiated transplant charges

The estimate of out-of-pocket expenses is based on the information submitted and available to Aspirus Health Plan at the time of our response. The estimate will not assume any complications occur or modifications are made to the treatment plan. To download and mail your estimation of out-of-pocket expense form, please refer to our Estimate Out-of-Pocket Expenses resource page.

When should I see a doctor?
When you’re not feeling well, it's hard to wait a few days for a doctor appointment. Many of our participating practitioners have extended hours and are available evenings, weekends, and holidays. Please call your doctor’s office if you have a question about a minor injury, illness, or other concern. One of their health care professionals will answer your medical questions and help you decide if you need to see a doctor immediately or if you should schedule an appointment with your primary care practitioner. They may also offer treatments that can be done at home to increase comfort and speed recovery.

Do you need care now and can't wait? As an Aspirus Health Plan member, you have access to telehealth services from MDLIVE with your health plan. By phone or internet, you get 24/7/365 access to board-certified physicians who can treat a variety of minor medical conditions from your home or work. For more information or to see a list of medical conditions, please refer to our Telehealth Services resource page.

*This service is optional for self-funded groups. Check your plan or talk to your agent for more information on adding this great benefit for your employee