Frequently Asked Questions
Why do I have to see my primary care physician (PCP) before seeing a specialist?
Your primary care physician (PCP) has a history with you and knows your specific health problems. Your PCP can evaluate your medical condition and determine when you need to see a specialist physician.
How do I change my (enrollment) information?
Changing your address or adding a dependent must be coordinated through your trust administrator directly. EHS is electronically linked to all of our health plans and they transmit your enrollment information to us on a regular basis.
What do I need to know about making an appointment with my primary care physician?
To schedule an appointment, call your doctor’s office during regular office hours. Please call as far in advance as possible to ensure optimum service.
Your doctor respects your time and makes every effort to honor scheduled appointments on time. However, unforeseen situations or emergencies do sometimes arise. We ask your patience if this does happen and your appointment runs later than expected. To expedite processing, please bring your health plan card or enrollment form to each appointment as well as a list of all of your medications and your medical history.
Please remember, you are responsible for your copayment at the time of your visit.
How do I gain access to a specialist?
Your doctor will discuss your condition with you and determine if you should see a specialist. He or she will submit an authorization request to EHS if that treatment is deemed “medically necessary.”
EHS reviews all authorization requests based on medical necessity, benefit coverage and whether or not the recommended specialist is available through your individual health plan. Once the authorization request is received, EHS will respond within five business days. If you do not hear from EHS within that time period, call your doctor as soon as possible. If an emergency arises, call your doctor. If you are stricken with a life-threatening illness or injury, dial 911 immediately or go to the nearest hospital emergency department.
Responses to most non-urgent (not immediately life threatening) referral requests will be called into your doctor’s office within 48 hours. Please do not schedule appointments prior to receiving an authorization. EHS encourages you to schedule an appointment immediately after receiving written approval. If you have questions about this process, call EHS at (800) 231-1407.
What do I do in the event of an emergency?
Whenever possible, call your PCP. If the situation is serious enough to require immediate care but is not life-threatening, call your PCP immediately to arrange services. In the unlikely event that you are unable to reach your doctor, call (800) 231-1407 to access our after-hours nursing staff.
If the situation is a life-threatening illness or injury, such as a heart attack, stroke or severe bleeding, dial 911 immediately or go to the nearest hospital emergency department.
What is the difference between Emergency and Urgent Care Services?
Emergency Services are required when a sudden injury could result in permanent physical impairment or loss of life. Chest pains or excessive bleeding may be examples of Emergency Services.
Urgent Care services are required when a sudden injury or serious illness requires immediate attention and would NOT result in a permanent physical impairment or loss of life.
Click here for a list of EHS urgent care facilities.
When is it appropriate to seek Emergency Room treatment?
If the situation is a life-threatening illness or injury, such as heart attack, stroke or severe bleeding, dial 911 immediately or go to the nearest hospital emergency department. Chest pains, excessive bleeding and broken bones would be situations where your condition would warrant emergency room treatment. Otherwise, call your PCP. If the situation is serious enough to require immediate care but is not life-threatening, call your PCP immediately to arrange services. In the unlikely event that you are unable to reach your doctor, call (800) 231-1407 to access our after-hours nursing staff.
Who reviews and makes the decision on my doctor’s authorization request?
Your doctor’s request is reviewed and a decision is made by the EHS Utilization Management Department, which is comprised of knowledgeable nurses and doctors. It is rare for an authorization request to be denied.
To ensure that you receive the best possible care, EHS uses evidence-based guidelines and criteria to make authorization decisions. The criteria and guidelines we use include (but are not limited to):
- Apollo guidelines
- EHS clinical guidelines
- Health plan guidelines
- McKesson InterQual
- Milliman Care guidelines
- Nationally recognized resources (Examples include: Centers of Medicare and Medicaid; ACOG: American College of Obstetrics & Gynecology; AAFP: American Academy of Family Practice; Centers for Disease Control; Food and Drug Administration; The United States Preventative Services Task Force, Child Health and Disability and Prevention Program, etc.)
EHS Appropriate Utilization of Care Affirmation Statement:
EHS has systems in place to assure appropriate care is provided to its members. These systems include the following guidelines:
- Utilization decisions are based only on appropriateness of care and service.
- No person involved in the authorization process may receive compensation for denials.
- No person involved in the authorization process may receive an incentive, either financial or non-financial, directly or indirectly to encourage denials.
- The utilization process must include systems to monitor for underutilization for services. The process shall include analysis of monitoring reports, identification of issues, development of improvement action plans to address these issues and finally, evaluation of the actions taken.
What rights do I have if I am denied approval to see a specialist or for a test or procedure?
You may submit a grievance or an appeal. To do so, please submit a copy of your denial notice and a brief explanation of your situation, or other relevant information to your union’s trust administrator. The trust administrator will document and process your appeal or grievance and provide you with a written notification of the decision. You may write, call or fax your grievance to your union’s trust administrator.
Will I be responsible for any provider bills other than an office visit copayment?
If you see a physician who is out of the EHS network, services are limited and you may have to pay the difference. It is important to stay within the network.
What do I do if I receive a bill for services that were authorized and I was eligible at the time of service?
Contact EHS at (800) 231-1407 and we will help you solve the problem. For efficient resolution, make sure you have the following information available when you call: your insurance identification number, the authorization number associated with the services in question, and the name of the physician who provided the services.
Who do I call if I need to change my primary care physician?
EHS Union members do not need to choose a primary care physician – you can visit any primary care physician within the EHS union network. However, building a relationship with one physician who knows your medical history can help with disease management and prevention.