Medical Management

All members need a primary care provider or Women’s Healthcare Provider (PCP or WHCP)

What is a PCP/WHCP?

This is your primary doctor that you picked when you enrolled with us.
A PCP/WHCP is a medical provider who will manage your health care.
PCP/WHCP includes family physicians, general practitioners, internists, or pediatricians.
A PCP/WHCP will help you get all the covered services you need.
It is important that you talk to your PCP/WHCP about any health problems you may have.
It is important to have a good relationship with your PCP/WHCP. Your doctor will get to know you and your medical history.
Always listen to your PCP/WHCP about your health care and check with your PCP/WHCP before you get medical services from other doctors.

You will need to show your Aetna Better Health of Illinois Family Health Plan ID cards each time you go to a doctor.

How do I pick my PCP/WHCP?

When you join Aetna Better Health of Illinois Family Health Plan, you will need to pick a PCP/WHCP for yourself and your eligible family members.

You must pick a PCP/WHCP in the Aetna Better Health of Illinois Family Health Plan provider network. The Provider Directory has a list of PCP/WHCPs to pick from in your area.
Each eligible family member does not have to have the same PCP/WHCP.
If you do not pick a PCP/WHCP, we will pick one for you.

How do I change my PCP/WHCP?

Your PCP/WHCP is an important part of your health care team. We want you and your doctor to work together. If you want to choose or change your PCP/WHCP to another doctor in the Aetna Better Health of Illinois Family Health Plan provider network, call Member Services toll-free at 1-866-212-2851.

In most cases, the PCP/WHCP change will happen on the same day as your request.
You will get a new Aetna Better Health of Illinois Family Health Plan ID card with the name of your new PCP/WHCP.
You may change your PCP/WHCP up to three times each benefit year without reason.
Please call Member Services to speak with a representative if you would like to change your PCP/WHCP.

Notice of provider changes or service locations

Sometimes we will have to change your PCP/WHCP without talking to you first. If this happens, you will be allowed to pick another PCP/WHCP by calling Member Services. An example might be if your doctor decides he/ she does not want to be a part of the Aetna Better Health of Illinois Family Health Plan provider network or they move to another location. If you are not sure if a provider is in our network, we can help. Check our website or call Member Services toll-free at 1-866-212-2851.

How do I set up a doctor visit?

It is important to take charge of your health care. When you get your Aetna Better Health of Illinois Family Health Plan ID card, call your PCP/WHCP for a regular check-up. This is called an Initial Health Assessment. If you went to your doctor recently because you were sick, you still need to set up a visit with your PCP/WHCP for a check-up. You should always call and set up a time before you go to see your PCP/WHCP. This will let your PCP/WHCP spend as much time with you as you need. Your PCP/WHCP may not be able to see you if you do not call first.

To see your PCP/WHCP, call the office to make an appointment. Routine care visits can be scheduled within three weeks of your call. Your PCP/WHCP and/or nurse will help you get the care you need. Doctors’ offices may be open at different times. Always tell the doctor’s office that you are an Aetna Better Health of Illinois Family Health Plan member and the reason you need to see the doctor.

Be sure to take all your ID cards and a list of any medications you are taking. If you are going to your child’s PCP/WHCP, take your child’s ID cards and your child’s record of shots. Sometimes, you or your children will need to see the PCP/WHCP sooner. For example, your child might have an earache. Call the PCP/WHCP’s office right away and tell him or her about the child’s symptoms. Ask to bring your child in that day. Most offices keep some time open just for these problems. If you need urgent care, your PCP/WHCP will either see you within 24-48 hours, or tell you where you can go to get care.

How do I cancel or change a doctor visit?

When you schedule a visit with a doctor, that time is important. Doctors see lots of patients and must make time for all of them. If you need to cancel or change your visit with your doctor, let the doctor’s office know at least 24 hours ahead of time. This will give the doctor more time to see other patients. A good relationship with your doctor is important. Being on time and letting your doctor’s office know if you must cancel helps build a good relationship.

Specialty care referrals

What is specialty care?

Specialty care comes from doctors (specialists) who are trained to treat certain specific problems such as your heart.

Some kinds of special health care needs will mean that you need to visit a specialist instead of your PCP/WHCP. An example of a specialist could be an ear, nose and throat doctor, a surgeon, allergist or pulmonary (lung) doctor. If you have questions, ask your PCP/WHCP or call Member Services.

When your PCP/WHCP sends you to see a specialist, it is called a referral. Your PCP/WHCP will suggest a specialist. Your PCP/WHCP’s office may set up the visit for you or ask you to set up a time that is best for you. If you think you need to see a specialist, talk to your PCP/WHCP about it.

A referral to a specialist is not required, as long as the specialist is in the Aetna Better Health of Illinois Family Health Plan provider network.

Let your PCP/WHCP know if you visit a specialist, so they can help you with your care. If you need help finding a specialist, your PCP/WHCP or Member Services can help you.

If a provider you want to see is not in our network, your PCP/WHCP must request prior authorization from us in order for you to see the out-of-network provider. Only your PCP/WHCP can make this request. It is not something you can do yourself.

Specialist services that do not require your doctor’s approval are called self-referral services. Some examples of self-referral services are family planning services and behavioral health services.

Prior authorization

Prior Authorization Steps

1. Your provider contacts us by phone, fax or online to ask for prior authorization. They tell us about the service and why you need it.

2. Our medical staff looks at the information to decide if the service can be approved. They may talk more with your provider.

3. If the service is approved, we tell your provider.

4. If the service is not approved, we send a letter to you and your provider. This is called a “Notice of Action letter.” It explains the decision.

5. You and your provider can get a copy of the medical reasons used to make a denial decision.

6. If you disagree with the decision, you can file an appeal or ask for a State Fair Hearing.

We do not reward a provider for denying, limiting or delaying coverage of health care services. We do not give money to staff that make medical necessity decisions to get them to turn down services.

You can call Member Services toll-free at 1-866-212-2851 if you have questions about this process.

Prior authorization process

1. Your health care provider must contact Aetna Better Health of Illinois Family Health Plan with information that can support the medical necessity for the service.

2. Aetna Better Health of Illinois Family Health Plan nurses will review the services requested and decide if it can be approved based on Aetna Better Health of Illinois Family Health Plan’s clinical guidelines. If the nurse cannot approve it, an Aetna Better Health of Illinois Family Health Plan doctor will review it. Our doctor may attempt to contact the requesting provider to discuss the request.

3. If the authorization is approved, your health care provider will be notified of the approval.

4. If a denial, reduction, suspension, or termination of your services happens, we will send you a “Notice of Action” letter. You will receive the letter at least ten (10) calendar days before the change to let you know. Your doctor will also be notified of this decision. More detailed information is explained in the Grievances and Appeals section of this handbook.

5. At any time, you and your provider may ask for a copy of the clinical criteria that was used to make a denial decision for medical services.

6. If you do not agree with the decision:

You may file an appeal with Aetna Better Health of Illinois Family Health Plan and/or
Request a State Fair Hearing

Aetna Better Health of Illinois Family Health Plan does not reward or pay extra money to health care providers, staff or other people to:

Deny you care
Give you less care
Deny tests or treatments that are medically necessary

As an Aetna Better Health of Illinois Family Health Plan member you are not responsible for paying for medically necessary covered services. You may be responsible for payment when the service provided is not covered by Aetna Better Health of Illinois Family Health Plan and your provider has told you that it is not covered before you received the service.

“Medical necessity” – definition

What is Medical Necessity? When your provider asks for prior authorization, they must tell us why the service is medically necessary.

A service is medically necessary if it meets the descriptions below.

It is appropriate.
It is considered by other health professionals to be good medical practice.
It meets Aetna Better Health’s guidelines, policies and procedures.
It is used to diagnose or treat a covered illness or injury.
It is used to prevent an illness.
It is used to help you get well or stay well.

This definition also applies to supplies and medicines.