Access to Care

Your PCP is the doctor or doctors’ group who provides and works with your other health care providers to make sure you get the health care services you need. Your PCP refers you to specialists you need and keeps track of the care you get by all of your providers.

A PCP may be a family doctor, a general practice doctor, a pediatrician (for children and teens), or an internist (internal medicine doctor). You may also pick a certified registered nurse practitioner (CRNP) as a PCP. A CRNP works under the direction of a doctor and can do many of the same things a doctor can do such as prescribing medicine and diagnosing illnesses.

Some doctors have other medical professionals who may see you and provide care and treatment under the supervision of your PCP.

Some of these medical professionals may be:

• Physician assistants
• Medical residents
• Certified nurse midwives

If you have Medicare, you can stay with the PCP you have now even if your PCP is not in UPMC for You’s network. If you do not have Medicare, your PCP must be in UPMC for You’s network.

You can ask for a specialist to be your PCP. The specialist needs to agree to be your PCP and must be in UPMC for You’s network.

Enrollment specialists can help you pick your first PCP with UPMC for You. If you do not pick a PCP through PA Enrollment Services within 14 days of enrollment, we will pick your PCP for you.

PCPs and obstetrician-gynecologists (ob-gyns) must have at least 20 office hours per week.

You should not have to wait in the waiting room longer than 30 minutes for routine care, unless the doctor has an emergency.

When can I see my new PCP?

A medical condition presenting with acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part.

Here are some examples of emergencies:

• Heart attack
• Chest pain
• Severe headache (a possible sign of stroke)
• Severe bleeding
• Unconsciousness
• Poisoning
• Sudden loss of feeling or not being able to move
• Strong feeling that you may kill yourself or another person
• Severe pain

If you have an emergency, go to the nearest emergency room, call 911, or call your local ambulance service. The emergency room must perform an appropriate initial screening examination to see if an emergency condition exists. The hospital will conduct more examinations and treatments to stabilize your medical condition. If the hospital finds you need to be transferred to another facility, they will advise you of the risks and benefits, get your written consent, and get an authorization from UPMC for You. You must call your PCP for any follow-up care needed after your visit to the emergency room. If you need help arranging care, please call the Health Care Concierge team at 1-800-286-4242 (TTY: 711). Help is available at these days and times:

• Monday, Tuesday, Thursday, and Friday from 8 a.m. to 6 p.m.
• Wednesday from 8 a.m. to 8 p.m.

If you get follow-up care with someone other than your PCP without a referral, UPMC for You may not pay the bill. If you have questions about a bill, please call the Health Care Concierge team.

If you have an emergency and need to be admitted to the hospital, you should tell your PCP. Call within two days or as soon as you or a family member can call. If you are admitted to a hospital that does not accept UPMC for You members, you may be moved to a UPMC for You participating hospital. You will be moved only when you are strong enough.

Consider UPMC AnywhereCare.* With this service, you can do an e-visit with a UPMC provider straight from your computer, tablet, or phone. Anytime, day or night. And there is no cost for UPMC for You members.

UPMC AnywhereCare is perfect for problems such as a sore throat, cough, runny nose, sinus infection, cold or flu symptoms, back pain, and poison ivy. Simply sign in and describe your symptoms. A provider will get back to you—often within minutes—with a diagnosis and care plan. You can even get a prescription if needed.

Benefits of UPMC AnywhereCare include:

• One more way to access great health care.
• Less serious conditions get taken care of before they become more serious.
• Less time from your day because e-visits take minutes, not hours.
• Peace of mind that you’re always covered when symptoms arise.

Visit UPMC AnywhereCare for more information or to sign up.

 

With UPMC Children’s AnywhereCare, children ages 0-17 can have virtual visits 24/7 with UPMC Children’s Hospital of Pittsburgh providers over live video. Providers can screen children and provide treatment for conditions commonly treated by a pediatrician or urgent care provider.**

*UPMC for You members who are in Pennsylvania at the time of a virtual visit may select a UPMC-employed provider, subject to availability and discretion of the provider. Members temporarily traveling outside of Pennsylvania at the time of service will receive care from a provider employed or contracted by Online Care Network II PC (OCN), also known as Amwell Medical Group. OCN is not an affiliate of UPMC. UPMC AnywhereCare virtual visits are not covered services for UPMC for You members using Talk Therapy or Psychiatry services. Providers are not available to treat members who are in Puerto Rico.

**UPMC Children’s AnywhereCare is available only to patients who are in Pennsylvania. In order for a child to have a UPMC Children’s AnywhereCare visit, the child’s parent or legal guardian must be with the child during the video portion of the visit, and the child and parent or legal guardian must be in Pennsylvania during the visit. If a child is located outside of Pennsylvania at the time of service, their parent or legal guardian may select the standard UPMC AnywhereCare module, and the child will receive care from a provider employed or contracted by Online Care Network II PC (OCN), also known as Amwell Medical Group, at the discretion of the provider. OCN is not an affiliate of UPMC. Providers are not available to treat members who are in Puerto Rico.