HMO Member Tips
Referrals to specialists must be coordinated by your Primary Care Physician (PCP), who is responsible for the overall management of your healthcare. Most referrals are confirmed by a referral authorization letter which includes the specialist name, number of visits and expiration date of the referral. Your Primary Care Physician should make arrangements for your appointments. Prior authorization will need to be obtained prior to making any appointments for most services.
Checking Referral Status
Call the UM Department at (559) 735-3892 or (559) 735-3893. We are available Monday through Friday from 8:00 AM-5:00 PM. You may also check with your doctor's office.
Laboratory services are capitated. Members assigned to Visalia or Exeter primary care providers are required to use Kaweah Delta Health Care District. Members assigned to Tulare primary care providers are required to use Tulare District Hospital and members assigned to Dinuba, Lindsay, Porterville, Hanford, Corcoran, and Lemoore primary care providers are required to use Quest Diagnostics. For locations of draw sites please click here.
(For medical questions that are NOT an emergency)
The Urgent Care Center is not a substitute for your primary care physician. Many times visits are denied because the member thought that because it was after normal office hours, the urgent care was the only option for them. Your primary care physician, or an on call physician is available to you 24 hours a day. A good rule of thumb is: If you wouldn't call your doctor after office hours about your condition, chances are that you do not need to go to the urgent care. You should call your Primary Care Physician. Your doctor may want to see you immediately or schedule an appointment. For more information about using urgent care services please click here.
Emergency Room Access
Perhaps the most commonly denied service is medical care obtained through the emergency room or urgent care center. Often this results in angry responses from those denied coverage, as these services can be quite expensive. You can save yourself both time and money by following some general guidelines.
Contact your primary care provider regarding your condition before going to the E.R. or Urgent Care Center. Often symptoms you consider emergent can be handled over the phone. Sometimes antibiotics can be prescribed for urinary tract, sinus, or ear infections. High fevers in children are rarely emergent and can be managed with combinations of Tylenol, Ibuprofen and a cool washcloth. Pain management; whether low back, headache, abdominal, or limb; can also be evaluated and treated over the phone depending on its severity. Vomiting and diarrhea can often be relieved by over-the-counter and prescription medications. It is important to call your doctor before going to the emergency room or urgent care center so he/she can best advise you on what to do.
Certainly some conditions are so emergent that you do not have time to contact your physician. Sudden onset of severe chest pain, shortness of breath, loss of consciousness, weakness on one side of the body, new seizures and persistent fast irregular heartbeats are all indications of potentially serious conditions. Injuries resulting in an obvious fracture or open wound also require immediate care. In these cases, contact your physician the following day so they can request authorization for the E.R. or urgent care.
Hopefully you will never need urgent/ emergent care. If you do, however, following these guidelines may save you time and expense in the future. If you and others follow these guidelines this may insure that the emergency room physician will be able to see you in a timely manor and reduce unnecessary time to see non-emergent conditions.
Direct Access for Women
Under the HMO’s, women have direct access to contracted OB/GYN’s within the Key Medical Group panel. Direct access means the member can see the OB/GYN without a referral for evaluation and management services. A Key Medical Group provider can perform or request up to $500.00 worth of services. Services over $500.00 need to have prior authorization.
For a list of Key Medical Group contracted OB/GYN providers please go to our Resource Page and download the specialist file.