Open access benefit plans: No referral or PCP approval is required for members to see other network care providers. Prior authorization and notifications are required for certain services, described in Chapter 6: Medical Management, with the exceptions noted in the previous table. Benefit plans vary in the type of coverage offered based on network and tier status (for tiered benefit plans only).
Gated benefit plans: Members must select and see their assigned PCP. The PCP must submit electronic referrals before a member sees another network physician; this helps ensure the highest level of coverage. Benefit plans vary in type of coverage offered based on PCP and referral requirements, network status, and tier status (for tiered benefit plans only).
Tiered Benefit Plans: Plans define tier 1 care providers differently. Check your tier status when verifying eligibility using eligibilityLink. Some of our commercial products feature tiered benefits. NexusACO is always offered as a tiered benefit plan. Members may have lower out-of-pocket costs for services provided by a tier 1 care provider or facility. Members with a tiered benefit plan have an identifier on the front of their health care ID card.
W500 Additional Network Benefits
Some benefit plans include Additional Network Benefits referred to as W500 Emergent Wrap. We contract with non- participating care providers to provide network coverage for urgent, emergent and gap exception services. This extends the network of care providers available to members outside their primary network for these services. Members with additional network benefits display W500 on the back of their ID card.