Physicians and Other Providers
Please note: The benefits information contained in this “Frequently Asked Questions” is for general information only. For more specific benefits information, please consult your certificate of coverage or other plan documents.
How do I find a network provider?
These providers may be found in the Provider Directory. You should have received a directory of providers during your employer's open enrollment process. If you did not receive a directory or would like a more recent version please, call Member Services at the number on the back of your ID card. A Member Services representative will mail you a printed directory, which we update twice a year.
Search our online directory
, which is updated monthly.
What is a primary care physician (PCP)?
A PCP acts as the patient's regular physician and can help coordinate other care the patient may need, such as a visit to a specialist or hospital. He or she typically practices family, internal or pediatric medicine. The PCP’s educational background enables him or her to give you a solid, overall picture of your health. Member Services can provide you with more specific information about the PCPs and specialists listed in our directories (if available). This may help you find a physician that meets your cultural, ethnic or other special needs or preferences (i.e., you may prefer a female or Spanish-speaking physician). Check your contract or Certificate to know what is required of you.
What are the advantages of using network providers?
Many of our networks are made up of providers who have met certain quality standards that we have established. Many of our benefit designs require that you receive treatment from a network provider to obtain any benefits or the highest level of benefits. If you use a network provider, the provider is responsible for obtaining any precertification required under your contract or Certificate. He or she will also file your claims for you and will seek payment from us for covered services. You will only have to pay the applicable copayments, deductibles and coinsurance. If you receive treatment from a non-network provider, you could be financially responsible for more than just copayments and deductibles. Check your contract or Certificate for more information.
What happens if my current physician is not a network provider?
If your benefit design requires you to use a network provider, you could ask your physician to contact us for a participation application. However, until such time as that physician becomes a provider in the network, you will need to change to a network physician in order to receive the highest (or any) level of benefits. There may be some exceptions to this rule. Check your contract or Certificate.
How do I choose/change my PCP?
You can select a PCP on your enrollment application prior to becoming an Anthem member. If you did not select a PCP at enrollment, or if you want or need to change your current PCP you should:
| Select a PCP from your provider directory. |
| Call the Member Services number on your ID card to advise them of the change. |
| Ask Member Services when the PCP change becomes effective. It takes time to process a PCP change so the effective date will depend on when Anthem is notified. Make sure the change is effective before you see your new PCP, otherwise the visit and any services provided may not be covered by your plan or may be provided at a higher cost to you. |
| Verify that your new PCP’s name or group appears correctly on your new member ID card. |
| Schedule a meeting to help you decide if you feel comfortable with your new PCP. |
Can I change my PCP any time I want?
We encourage you to develop a long-term relationship with one physician, but you can change primary care physicians if you feel it is necessary. Select your new physician from the Anthem Provider Directory
, then contact Member Services to make the change.
What if my primary care physician cannot see me right away?
Check your contract or Certificate for details. However, keep in mind that, regardless of the type of coverage, if you are experiencing an emergency, you should call 9-1-1 or go to the nearest hospital to receive care. However, you should call us within 24 hours (48 hours in Indiana) of going to the hospital, in order to receive the maximum benefits for covered services.
The time period for contacting us may be different, depending on what your contract or Certificate says. The time frames in your contract or Certificate language will apply if in conflict with the time frames of this answer.
Emergency care is defined by your contract or Certificate, but generally means those health care services that are provided in an emergency facility or setting after the onset of an illness or medical condition that manifests itself by symptoms of sufficient severity that without immediate medical attention could be reasonably expected by the prudent lay person, who possesses an average knowledge of health and medicine, to result in:
| Placing the member's physical and or mental health in serious jeopardy; |
| Serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. |
If you are in need of urgent care and your PCP is unable to see you right away, you should pursue care appropriate to your situation, regardless of what your benefits will pay. Urgent care may not be covered to the same extent as emergency care. Urgent care is defined by your contract or Certificate, but typically means services received for an unexpected episode of illness or injury requiring treatment which cannot be postponed, but is not emergency care. Urgent care conditions include, but are not limited to, earache, sore throat, fever not higher than 104º. Treatment of an urgent care condition does not require use of an emergency room at a hospital.
Check your contract or Certificate to see whether urgent care is covered. Typically, urgent care is covered if provided in a non-emergency room setting by a network provider.
If the service you are receiving is for something other than emergency or urgent care, it may or may not be covered. For example, if you are enrolled through an HMO product, there is no coverage for services rendered by a non-network provider, unless approved by Anthem. Except for our HMO products, our benefit designs typically do have some level of benefits for medically necessary care received through a non-network provider. Contact Member Services for more information and for guidelines that apply specifically to you.
What if my network provider isn't available to treat my condition?
You can access a list of network providers by visiting our online provider directory. Check your certificate for more information.
Can I go to a non-network provider?
Yes, although it may result in our paying a lower level of benefits or nothing at all, depending on the product design under which you are covered. Check your contract or Certificate for more information.
How do I obtain health care for different types of services?
Care must be received from your Primary Care Physician (PCP) or another Network Provider to be a covered service. The Schedule of Benefits will direct you as to how to obtain specialty care including Behavioral Health Services, Inpatient Services, Outpatient Services, Physicians Home Visits & Office Services and will include any applicable deductible, coinsurance, copayment and benefit limitation information.