Health Advantage

Selecting or Changing Your Primary Care Physician (PCP)

At the time of enrollment, you must select a primary care physician (PCP) from the Provider Directory for your health plan. Your membership ID card will list the PCP you select. Each member of your family covered by your health plan also must select a PCP, but each family member may select a different PCP.

HMO Members

If you are enrolled in an HMO plan, covered services must be performed, prescribed, directed or authorized in advance by your PCP and/or Health Advantage except in an emergency or for gynecological services or a routine vision examination from a participating provider.

If your services are not authorized by your PCP, your claims may be denied. Note that your PCP will need to contact Health Advantage in advance for any referral to out-of-network providers.

POS Members

If you are enrolled in a POS plan, the key to obtaining in-network benefits from Health Advantage is your PCP. Services allowed under your health plan that are performed, prescribed, directed or authorized in advance by your PCP and/or Health Advantage are covered as in-network benefits. Note that your PCP will need to contact Health Advantage in advance for any referral to out-of-network providers.

You must contact your PCP prior to receiving any health services except in an emergency or for gynecological services or a routine vision examination from a participating provider. Your claims will be paid at the out-of-network level for services by either an in-network or out-of-network provider if your PCP does not authorize those services in advance.

Open Access POS Members

Under Open Access POS, you self-direct to your choice of providers -- your PCP for preventive and routine services or in-network or out-of-network specialists for episodic care. Referrals are not necessary.

However, covered preventive services must be performed by a PCP. Otherwise, those claims may be denied.

Even though you don't need referrals to specialists if you are enrolled in Open Access POS, you should choose in-network providers to reduce your health care cost. Copayments, deductibles and coinsurance are substantially higher if you choose out-of-network providers. Arkansas State and Public School enrollees are not required to select a Primary Care Physician.

Resources

For a list of participating providers, go to the Provider Directory.

For more information on referrals, see Member Referral Process.