1.
Why was my ER visit denied?
The ER should be used for
the following: (a) Conditions that would place a patient's
health in serious jeopardy (b) serious impairment to bodily
functions (c) serious dysfunction of any bodily organ or part.
If after review your ER visit, it is determined that emergency
services did not meet the criteria, the member will be
responsible for the charges incurred.
2.
What do I do for medical services
while I (or my dependants) are out-of-town?
First, always contact your
Primary Care Physician. Your PCP may be able to call in a
prescription to a local pharmacy for you until you return
home.
If the services needed are
considered serious or life threatening, go to the nearest
emergency room. Evergreen will ensure payment to
non-contracted providers for the appropriate out-of-area
emergency services. Routine or urgent care will not be covered
out-of-town.
3.
Why am I getting a bill from the
hospital or physician & what should I do when I receive one?
If you receive any bill for
services other than routine co-payments, immediately call
Evergreen Member Services. Someone will research your
statement and let you know if you are responsible for payment.
There are certain services provided that are exclusions of the
Evergreen plan, and the member could be responsible for those
charges.
4.
Can a referral be done by a
Specialist as well as my PCP?
The PCP is responsible for
requesting the referral and referring patients to an
in-network specialist. It is the responsibility of the
ordering physician to obtain pre-authorization when required
for specific procedures and all hospital admissions. The
specialist can get a referral to another specialist if needed.
5.
If I am sick, what is the
criteria for the physician to schedule an appointment for me?
If a patient needs urgent care, an appointment should be
scheduled no later than 48 hours. patients should not be sent
to the Emergency Department as a convenience.
If you cannot find an answer to your question feel free
to contact us via
email or
fill out our contact form.
