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Access to Care

Primary Care Provider (PCP)

 

How do I choose a PCP?

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 the EAP within 14 days of when you picked UPMC for You, we will pick your PCP for you.

 

How many hours per week will my PCP’s office be open?

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

 

How long will I have to wait in the office to see my PCP?

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

 

Will my PCP’s office be accessible for individuals with disabilities?

All provider offices must meet the Americans with Disabilities Act (ADA) accessibility guidelines.

 

When can I see my new PCP?

UPMC for You wants to be sure you are getting health care when you need it. That is why there are standards for appointments at the provider’s office. Your health care needs determine the kinds of visits you need and how soon providers should see you.

It is important that you get to know your PCP. Call and make an appointment for a visit soon after you become a member. When you make the appointment, tell your PCP if you have any medical insurance in addition to UPMC for You. You should give your PCP as much information as possible about your health. This includes family history, past illnesses, medicines you are taking, and any current health problems or concerns you have.

Your PCP selection is effective immediately after you call the Health Care Concierge team and tell us the name of your PCP. We will send you a new UPMC for You ID card with the name and phone number of your PCP. Keep your current UPMC for You ID card until you get your new one. Your PCP is always the first person you should call for routine or nonemergency health care needs.

Emergency Department Care

 

What if I need emergency care? What is an emergency?

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 7 a.m. to 7 p.m.
  • Wednesday from 7 a.m. to 8 p.m.
  • Saturday from 8 a.m. to 3 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.

 

What if I get admitted to the hospital because of an emergency?

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.

UPMC AnywhereCare

 

What if I need nonemergency care right away and can’t get to the doctor?

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 located in Pennsylvania at the time of the virtual visit may select a UPMC-employed provider or a provider from Online Care Network II, P.C. (OCN), subject to availability and discretion of the provider. During the COVID-19 emergency declaration, members located outside of Pennsylvania will receive service from OCN. OCN is not an affiliate of UPMC. After the COVID-19 emergency declaration, UPMC AnywhereCare virtual visits will not be covered services when UPMC for You members are traveling outside of Pennsylvania.

**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 you are located outside of Pennsylvania at the time of service, you may select the standard UPMC AnywhereCare module and you will receive care from a provider employed or contracted by Online Care Network II P.C. (OCN) at the discretion of the provider. OCN is not an affiliate of UPMC. During the COVID-19 emergency declaration, UPMC for You members located outside of Pennsylvania will receive service from OCN. After the COVID-19 emergency declaration, UPMC AnywhereCare virtual visits will not be covered services when UPMC for You members are traveling outside of Pennsylvania.

UPMC MyHealth 24/7 Nurse Line

Whether you are seeking general health advice or information regarding a specific medical issue or just need quick assistance, the UPMC MyHealth 24/7 Nurse Line has registered nurses to provide prompt and efficient service.

The UPMC MyHealth 24/7 Nurse Line is available 24 hours a day, seven days a week. Just call 1-866-918-1591. TTY users should call 711. Be sure to have your ID card ready.

UPMC nurses who answer calls are licensed to assist members in Pennsylvania, West Virginia, Maryland, New York, and Ohio. Members must be located in one of those states when calling the UPMC MyHealth 24/7 Nurse Line. The UPMC MyHealth 24/7 Nurse Line is not a substitute for medical care. If an emergency arises, call 911 or go to the nearest emergency department. Nurses cannot answer plan or benefit questions. Please call the Member Services number on your member ID card for nonclinical inquiries.

Behavioral Health Care

Behavioral health services include both mental health and substance use disorder services. These services are provided through behavioral health managed care organizations (BH-MCO) that are overseen by the Pennsylvania Department of Human Services’ Office of Mental Health and Substance Abuse Services (OMHSAS).

You do not need a referral from your primary care provider (PCP) to get behavioral health services, but your PCP will work with your BH-MCO and behavioral health provider(s) to help you get the care that best meets your needs. You should tell your PCP if you or someone in your family is having a mental health or substance use problem.

You can find the BH-MCO that serves your county here. The BH-MCO can help you find providers that treat mental health and substance use disorders.

You can call your BH-MCO toll-free 24 hours a day, 7 days a week. You can also call the UPMC for You Health Care Concierge team at 1-800-286-4242 to get contact information for your BH-MCO. TTY users should call 711. Help is available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m.; Wednesday from 7 a.m. to 8 p.m.; and Saturday from 8 a.m. to 3 p.m.

If you have questions about transportation to behavioral health care appointments, you should contact your BH-MCO.

If you are thinking about suicide, are worried about a friend or loved one, or would like emotional support, call the National Suicide Prevention Lifeline at 1-800-273-8255. Help is available 24/7 across the United States.

Beginning July 16, 2022, dialing “988” will route calls to the National Suicide Prevention Lifeline. The 988 dialing code will be available nationally for call, text, or chat. The current Lifeline phone number (1-800-273-8255) will always remain available to people in emotional distress or suicidal crisis, even after 988 is launched nationally.