Doctors, hospitals, facilities (such as labs) and other professionals who give health care services may have a contract with us. If they do, they're in our network - also called in-network providers. That means they've shown they provide quality care and they accept our payment rates when our members go to them for care. If they don't have a contract with us, they're outside of our network - or out of network providers.
Many of our networks are made up of providers who meet high quality standards. Network providers are responsible for getting any needed preauthorization (approval) of your care. They also file your claim for you and will seek payment from us for covered services. When you see network providers, you only have to pay the copays, deductibles and coinsurance required by hour health plan.
If you get treatment from a provider outside the network, you may be responsible for getting preauthorization for a proposed service. You could have to pay more for services done outside of your network. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.
If you have questions or to check if your treatment needs preauthorization call the Member Services number listed on the back of your ID card.
Yes, although it does not make the most of your benefits and may end up costing you more. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) to learn more.
NOTICE: There are hospitals, health care facilities, physicians or other health care providers who are not included in every plan network. Your financial responsibilities for payment of covered services may differ if you use a network provider or a non-network provider. Please refer to the online Find Care tool to determine if a particular provider is in the network, or contact customer service for assistance.
You could ask your doctor to call us and apply to join the network. Until your doctor becomes a provider in the network, changing to a network doctor will help you pay less and make the most of your benefits.
A primary care physician (PCP) is your main doctor. Always try to go to your PCP first for health concerns or questions.
Your PCP coordinates any other care you need, such as a visit to a specialist or a hospital stay. You may need to contact your PCP to get an OK (prior authorization) before you get certain services.
Most PCPs are family or general practitioners, internists or pediatricians. These types of doctors have gone to school to learn about all areas of health. That way, they can get a strong, overall picture of your health.
Not all health plans require you to have a PCP. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.
In emergencies, call 9-1-1 or go to the nearest hospital - you don’t need an OK from us or your PCP. But be careful not to use the emergency room unless it really is an emergency.
If it’s not an emergency, you can see a doctor right away online, using your phone or computer at livehealthonline.com. Depending on your plan, it’s likely about the same cost as your doctor.
You can also use our Find Care tool to look for an urgent care center - or a clinic in a retail shopping store. You can usually walk in without an appointment needed. And they can handle lots of urgent health issues like a flu or cold, allergies, prescribing medication, even small fractures and X-rays.
If it’s not an emergency, you can see a doctor right away online, using your phone or computer at livehealthonline.com. Depending on your plan, it’s likely about the same cost as your doctor.
You can also use our Find Care tool to look for an urgent care center - or a clinic in a retail shopping store. You can usually walk in without an appointment needed. And they can handle lots of urgent health issues like a flu or cold, allergies, prescribing medication, even small fractures and X-rays.
If your primary doctor can’t see you that day or the next, you should find an urgent care clinic nearby. Under Find Care, select Find Urgent Care for one in your network.
It can take up to 10 business days or two weeks.
Call them. They should always have someone available, or a recorded message to help you get the care you need.
Preapproval, sometimes referred to as "precertification or preauthorization," is the process used to confirm if a proposed service or procedure is medically necessary. Whenever possible, preapproval should occur before treatment is received.
The doctor who schedules an admission or orders the procedure or service is responsible for obtaining preapproval. Most doctors in your plan will know to contact Anthem at the Provider Services number on the back of your member ID card for benefit coverage information and to obtain preapproval for the care you may be scheduled to receive.
You may also contact Member Services at the number on the back of your member ID card to determine if a proposed test, equipment, service or procedure requires preapproval.
It is important to know if your doctor has obtained preapproval, particularly when visiting a doctor not in your plan who may or may not be familiar with Anthem’s policies and requirements. Failure of your doctor to secure a preapproval when required may result in denial of payment of a claim.
A referral is a recommendation by a doctor that a Member receive health care services from another specialist or facility. Some referrals may require preapproval.
If you are a member with an Individual plan:
If you have an HMO plan, you need to select a Primary Care Physician (PCP). A referral from your PCP is required to visit another doctor in your plan. Anthem must authorize and approve any service not in your plan, otherwise only emergency and urgent care are covered without an approval.
If you are a member with a Point of Service (“POS”) plan you need to select a PCP, but referrals are not required to see another doctor located in the state of Maine. If you go outside your plan, you will pay a higher cost share for coverage that is available. Services not in your plan outside the state of Maine include emergency and urgent care only.
Your PCP will work with you to decide if you need to see a specialist. If referrals are required, your PCP will refer you to a specialist in your plan. If your plan allows self-referrals to a specialist, you can search for a specialist in your plan using our online directory.
If you are a PPO Member, you are not required to select a PCP and do not need a referral. If you go outside of your plan, you will pay a higher cost share for coverage that is available
Variations to the standard referral rules may apply. To verify the specific requirements for your plan, including preapproval for certain services, check your plan document (your contract, Evidence of Coverage, Summary/Schedule of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.
If you are a member with a group plan:
If you have an HMO plan, you need to select a Primary Care Physician (PCP). A referral from your PCP is required to see another doctor in your plan unless you are a member of Access Blue New England. If you are a member with a Point of Service (“POS”) plan, you need to select a PCP. Referrals are not required to see a doctor other than your PCP; however, your out-of-pocket costs may be more if you self-refer to another doctor in your plan.
For services not in your plan, all HMO and POS members must obtain a PCP referral and preapproval from Anthem, unless you are a member on the Health Exchange POS plan.
Your PCP will work with you to decide if you need to see a specialist. If referrals are required, your PCP will refer you to a specialist in your plan. If your plan allows self-referrals to a specialist, you can search for a specialist in your plan using our online find care tool.
If you are a PPO Member, you are not required to select a PCP and do not need a referral If you go outside of your plan, you will pay a higher cost share for coverage that is available
Variations to the standard referral rules may apply. To verify the specific requirements for your plan, including preapproval for certain services, check your plan document (your contract, Evidence of Coverage, Summary/Schedule of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.
You may need to contact your primary care physician (PCP) or direct primary care provider who isn't included in the plan's provider network to get an OK (prior authorization) before you get certain services, including behavioral health services. Your PCP or direct primary care provider who isn't included in the plan's provider network will work with you to decide if you need to see a specialist. If so, your PCP or direct primary care provider who isn't included in the plan's provider network will refer you to a network specialist. If you have to refer yourself to a specialist, you can search for a network specialist in our online directory. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.
Note: A referral can be made by a direct primary care provider who isn't included in the plan's provider network, subject to plan confirmation of the direct primary care provider's relationship with the member.
A direct primary care provider is an individual who is a licensed physician or osteopathic physician or other advanced health care practitioner who is a non-plan provider, authorized to engage in independent medical practice in Maine and qualified to provide primary care services, who chooses to practice direct primary care by entering into a direct primary care service agreement with patients. The term includes, but is not limited to, an individual primary care provider or a group of primary care providers.
Note: A referral can be made by a direct primary care provider who isn't included in the plan's provider network, subject to plan confirmation of the direct primary care provider's relationship with the member.
Simply enter the number into the Find Care search bar and hit enter.
