• Primary Care Physician (PCP)
• How Can I Change My Doctor?
• Specialty Care Referrals
• When Do You Need a Referral?
• How Can I Get a Second Opinion?
• Arranging Your Care
• Out of Network Care
• Other Medical Staff in Your Doctor's Office
• More Information About Your Doctor
• Hospital Care
• Emergency Services
• When Out of Town
• Transportation for Medical Services

When you enrolled in Gateway Health Plan^®, you picked a Primary Care Physician (PCP). Your doctor will arrange your healthcare needs and work with Gateway to make sure that you get the care you need. You can have the same doctor for the whole family, or a different doctor for each family member. If you need an appointment, call your doctor. The doctor’s phone number is on your Gateway Health Plan^® ID card, and there is no charge for visits to your Primary Care Physician (PCP).

It is very important that you keep your appointments with your doctor. If you cannot make it for any reason, call the doctor’s office right away to let them know.

Your Primary Care Physician (PCP), or an on-call physician, is available 24 hours a day, 7 days a week, for whenever you need medical care. If you are having an emergency and must get immediate medical care, go to the nearest emergency room. If you do not need immediate emergency attention, call your Primary Care Physician(PCP) first. Your doctor will tell you what to do. If your doctor is not in, an answering service will give your doctor a message to call you back.

If you need a list of Gateway doctors, hospitals, dentists, or other special providers, call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988). A list of providers is also available on this website. It is important for your doctor to be able to see you when you need care. Gateway has appointment guidelines that Primary Care Physicians (PCP) and Specialists are asked to follow. These appointment guidelines are different for the reason you need to be seen:

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How Can I Change My Doctor?

If you want to change your Primary Care Physician (PCP) for any reason, call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988). Member Services will help you make the change and will tell you when you can start seeing the new doctor. Depending on when you call, you may not be able to see your new doctor until the 1st day of the next month. You will get a new ID card, which will have your new doctor’s name and phone number. The front of the card will also have an effective date to let you know when you can start seeing the new doctor.

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Doctors that work with a certain area of medical care are called specialists. Some types of specialists are heart doctors, skin doctors, or someone who does surgery. If you need special care that your Primary Care Physician (PCP) cannot give you, your doctor may send you to a specialist for care. This is called a “referral.” Your Primary Care Physician (PCP) and the specialist will work together for your total healthcare needs. If you go to a specialist without your Primary Care Physician’s (PCP) referral, you may have to pay the specialist’s bill.

A specialist may send you to receive special services or tests. Some of those tests and services also require a referral. Examples of services and tests that require a referral are:

• Angiograms
• Chemotherapy (Hospital Setting)
• Nerve Conduction Testing
• Bone Scans
• Endoscopies
• Sleep studies

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There are some special services that do not require a referral from your Primary Care Physician (PCP). You can go to any Gateway participating doctor for the services listed below without a referral:

• Obstetrical and gynecological visits (pelvic exams, PAP tests, mammograms, pregnancy care, woman care)
• Routine eye care
• Dental visits
• Your first chiropractor visit (further visits must be authorized)
• Endoscopies
• Sleep Studies

For Family Planning services, you can go without a referral to any doctor, whether the doctor is a Gateway participating doctor or not.

You do not need a referral for behavioral health services including mental health care (depression) or drug and alcohol abuse.

Gateway’s goal is for you to be seen by the specialist that can best treat you. If there are not at least two specialists in the list of Gateway participating doctors that can treat you, Gateway must approve a visit to a specialist that is not on the Gateway list. Your Primary Care Physician (PCP) can help you request Gateway’s approval. If your request is denied by Gateway, you may file a grievance.

If you have been seeing a specialist for an ongoing problem, the doctor can choose to be your Primary Care Physician (PCP). Please call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988) for help in getting your specialist to be your Primary Care Physician (PCP).

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You may want to be seen by a different doctor, other than the one you have been seeing, for a second opinion. Your Primary Care Physician (PCP) can refer you to another Gateway participating doctor for a second opinion. If you have any questions, please call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

There are some services that Gateway must approve before you can get them. This is called prior authorization. You may have to pay when a service is provided without prior authorization. There are doctors and nurses who work for Gateway to help your doctor choose the best way to take care of you. These doctors and nurses are part of Gateway’s Health Services Department. They make decisions about the care that is most likely to help you by using specific guidelines for medical decisions. The guidelines are based on whether the service is medically necessary. Medically necessary means the service or benefit will, or is reasonably expected to prevent the onset of an illness, condition or disability; is reasonably expected to reduce the physical, mental or developmental effects of an illness, condition, injury or disability; or will assist the member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Member and those functional capacities that are appropriate for Members of the same age.

If you need a service that must be approved by Gateway before it is done, your doctor will call Gateway’s Health Services Department to get an approval. The doctors and nurses in Gateway’s Health Services Department will look at all the medical facts given by your doctor within certain time limits to decide if this service is the best way to take care of you. There is no extra payment given to these doctors and nurses no matter what they decide about your care.

Some of the services that need to be approved before you have them are listed below:

• Hospital admission
• The use of a short procedure unit in a hospital for a dental operation
• The use of a short procedure unit in a hospital for certain medical operations
• Medical equipment for your home (some covered items under $500 only require your doctor’s prescription)
• Nurses to come to your home
• Physical therapy, occupational therapy or speech therapy
• MRI and CT scan (testing)
• Using a doctor or other provider not in Gateway’s network
• Ambulance service, except for emergencies
• Chiropractic services (except for the first visit)
• Hospice (care for the terminally ill or dying)
• Nursing home or rehabilitation admissions
• Surgery

There may be other services that need to be approved by Gateway first. Your PCP or other doctor must contact Gateway’s Health Services Department to get prior authorization for certain services. If you do not have approval from Gateway before getting these services, you may have to pay the bill.

If you need to have tests, or need an operation, your doctor will call Gateway to have the services approved. Gateway will suggest a place for treatment.

If a service is not covered under the plan, your doctor can ask Gateway for an exception. Gateway does not guarantee that all exception requests will be approved or covered.

If Gateway denied payment for a service that you already had, your doctor may ask for a “retrospective review” to change the decision. A retrospective review is a detailed look by Gateway’s Health Services Department at your records and information to determine if the services were necessary to keep you healthy.

If you are admitted to the hospital and your doctor feels that you may need more days of care, a “concurrent review” may happen. A concurrent review is a detailed review while you are still admitted. This is also done by Gateway’s Health Services Department to determine if the services are necessary to get you healthy.

You may request a copy of the criteria for medical necessity on which the decision was based by sending a written request to:

Gateway Health Plan^®
Member Services Department
US Steel Tower Floor 41
600 Grant Street
Pittsburgh, PA 15219-2704

Many doctors and hospitals participate with Gateway. They are called the “network.” There may be a time when you need to use a doctor or hospital that is not a part of Gateway’s network. If this happens, your Primary Care Physician (PCP) can call Gateway to make this request. The Health Services Department will check to see if there is a doctor or hospital within Gateway’s network that can give you the same care. If there is a doctor or hospital within the network, Health Services will let your doctor know.

New Gateway Health Plan^® members have the right to keep seeing an out of network doctor to finish a course of treatment. The doctor must agree to Gateway’s guidelines. If you have been getting ongoing care from a doctor that is not a Gateway doctor, and you need to stay with this same doctor to finish a course of treatment, please call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988)for help. Please keep in mind that any services received from providers not in our network must be approved by Gateway, otherwise you may have to pay for them.

If a request to use a doctor or hospital outside of Gateway’s network is denied, you can file a complaint with Gateway by calling Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988). If you receive services from a provider that is not in Gateway’s network without approval, that provider may be allowed to bill you.

Some medical offices may have other types of staff treating you besides doctors and nurses. These types of medical staff are called Physician Assistants and Nurse Practitioners. They are specially trained to work in your doctor’s office and to examine you. Your doctor will always oversee any treatment that you get. Some offices also have doctors working there, called “Residents,” who are finishing their training. Medical Residents work with your regular doctor to take care of you.

If you would like to know more about the education and training of your doctor, or anyone else treating you, call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988).

Your Primary Care Physician (PCP) or specialist will arrange all of your admissions to the hospital. You should not be admitted to a hospital without your doctor’s orders, unless it is an emergency as described below. If a doctor other than your Gateway doctor admits you to the hospital, you or your authorized representative should call your Primary Care Physician (PCP) within 24 hours of being admitted.

If a doctor other than your Primary Care Physician (PCP) or specialist admits you to a hospital for a problem that is not an emergency, you may have to pay your own hospital bills.

Call the Member Services Department at 1-800-392-1147 (TTY/TDD 1-800-654-5988) if you have any questions on hospital services.

You should only go to the hospital emergency room for emergency care. An emergency is a sudden start of a medical condition or severe pain that an average person with no medical training feels:

• Places the person’s health (or with respect to a pregnant woman, the health of the woman or her unborn child) in jeopardy
• Would result in serious harm to bodily functions
• Would result in serious harm to an organ or body part

Every situation is different. If you or your family has an emergency, go to the nearest emergency room or 24-hour care center. Dial 911 or the phone number for your local ambulance service.

The hospital should provide appropriate medical screening to determine whether or not an emergency medical condition exists regardless of your ability to pay for treatment, your citizenship, or the legality of your presence in the United States. Emergency medical condition means a medical condition that could reasonably expected to result in (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part.

There are times when it is hard to know what a real emergency is. If you call your Primary Care Physician (PCP) before going to the emergency room, the doctor can tell you what to do.

Here are some examples of times when you should use the emergency room:

• Blackouts
• Car accident
• Chest pain or heart attack
• Choking
• Criminal attack (i.e. mugging or rape)
• Danger of losing limb or life
• Difficulty in breathing
• Heavy bleeding
• Loss of speech
• Overdose of medicine or drugs
• Paralysis (not able to move)
• Poisoning
• Possible broken bones
• Seizures
• Vomiting (throwing up) blood

Here are some examples of when you probably do not need to go to the emergency room. At these times, if you call your Primary Care Physician (PCP), the doctor can tell you what you should do.

• Bruises or swelling
• Cold or cough
• Cramps
• Small cuts or burns
• Earache
• Rash
• Sore throat
• Vomiting (throwing up)

Your Primary Care Physician (PCP) should arrange all follow-up care after an emergency room visit. Do not go back to the emergency room for bandage changes, removal of stitches, cast checks, or more testing. Do not return to the emergency room unless you have another emergency.

When Out of Town

Gateway services many counties within Pennsylvania. Gateway is offered in:

• Adams
• Allegheny
• Armstrong
• Beaver
• Berks
• Blair
• Butler
• Cambria
• Carbon
• Clarion
• Columbia
• Cumberland
• Dauphin
• Erie
• Fayette
• Franklin
• Greene
• Indiana
• Jefferson
• Lackawanna
• Lancaster
• Lawrence
• Lebanon
• Lehigh
• Luzerne
• Mercer
• Monroe
• Montour
• Northampton
• Northumberland
• Perry
• Pike
• Schuylkill
• Somerset
• Susquehanna
• Washington
• Westmoreland
• Wyoming
• York

If you or your family members are out of the Gateway’s service area and have a medical emergency, such as a heart attack or a car accident, go to the nearest emergency room. Make sure that you or your authorized representative calls your Primary Care Physician (PCP) as soon as possible.

Sometimes you will need to get care for things that may not be considered a medical emergency, such as a cold or flu. If you become sick when you are out of Gateway’s service area and it is not a medical emergency, call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988). Member Services can connect you to your Primary Care Physician (PCP) at no cost to you. All of Gateway’s doctor offices have a doctor on call 24 hours a day. If the office is closed when you call, you will be able to leave a message with an answering service or on a machine, and the doctor will call you back. It is important to leave the phone number where you can be reached while out of town. If it is during normal office hours, you will speak to the office staff. The office staff will talk to the doctor about your problem and then tell you what to do. If you are not able to speak with a doctor, Member Services may also help you get the care you need.

If you need help getting a ride to a medical service other than an emergency, each county provides transportation through the Medical Assistance Transportation Program. Each county provides transportation services directly or hires a transportation provider depending on the resources available in the county. The transportation provided may be:

• Tickets or tokens to ride public transportation
• Milage reimbursement for use of a private car
• Paratransit services (for example, in a van)

You can also call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988), and you will be connected to the Medical Assistance Transportation Program (MATP) in your county.