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CCM Direct HMO Plan Provider DirectoryThis directory provides a list of CCM Direct’s plan providers. This directory is for Bronx, Kings, New York, Queens and Westchester Counties, State of New York. This directory is current as of January 1, 2008. Some plan providers may have been added or removed from the list after this directory was printed. To get the most up-to-date information about CCM Direct plan providers in your area, you can visit www.ccmny.org or call our Member Service Department at 1-877-226-8500, Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY users should call 1-800-650-2774. Table of Contents
What is the service area for CCM Direct? Section 2 - Choosing your Primary Care Physician (PCP)
What is a "PCP"? Section 3 - Getting care from specialists Section 5 - What if you need medical care when your PCP's office is closed?
What to do if you have a medical emergency or urgent need for care and your PCP's office is closed Section 6 - Getting care if you have a medical emergency or an urgent need for care
What is a medical emergency? Section 7 - For more information Section 8 - List of Plan Providers Section 1 - IntroductionThis directory provides a list of CCM Direct’s plan providers. It also includes basic information about how to get your covered services with CCM Direct. To get more detail information about your health care coverage, please see your Evidence of Coverage. You will have to choose one of our plan providers that is listed in this directory to be your Primary Care Physician (PCP). The term “PCP” will be used throughout this directory. Generally, you must get your health care coverage from your PCP. The “plan providers” listed in this directory have agreed to provide you with your health care coverage. In most cases, your health care coverage is covered under CCM Direct. You may go to any of our plan providers listed in this directory; however some services may require a referral. If you have been going to one plan provider, you are not required to continue going to that same provider. In some cases, you may get covered services from non-plan providers. What is the service area for CCM Direct? The counties in our service area are listed below: Bronx, Kings, New York, Queens and Westchester in New York State How do I find CCM Direct providers in my area? The CCM Direct Provider Directory is divided into physician and non-physician provider categories. The physician category is organized by county and then by physician specialties, including PCPs. The non-physician category is organized by county and they by service type. You can also visit www.ccmny.org or call our Member Service Department at 1-877-226-8500, Monday through Friday, from 8:00 a.m. to 5:00 p.m. TTY users should call 1-800-650-2774. What if I use non-plan providers to get my covered services? "Non-plan providers" are providers that are not part of CCM Direct. If you use non-plan providers, you may have to pay more. Care or services you get from non-plan providers will not be covered, except for ambulance services, emergency care, including hospital care after you are stable (known as post-stabilization), maintenance care, urgently needed care, renal dialysis (kidney), and any services which were ordered covered through an appeals process. What should I do if I have bills from non-plan providers that I think should be paid by CCM Direct? We cover certain health care services that you get from non-plan providers. These include care for a medical emergency, urgently needed care, renal dialysis (kidney) that you get when you are outside the plan’s service area, care that has been approved in advance by CCM Direct, and any services which were ordered covered through an appeals process. If a non-plan provider asks you to pay for covered services you get in these situations, please contact us at CCM Direct, 2401 White Plains Road, Bronx, New York 10467. You should never pay any non-plan provider more than what the plan is allowed by Medicare. The provider has a right to get his/her fees, but does not have a right to get them from you. Ask the non-plan provider to bill us first. If you have already paid for the covered services, we will reimburse you for our share of the cost. If you get a bill for the services, you can send the bill to us for payment. We will pay your non-plan provider for our share of the bill and will let you know what, if anything, you must pay. Getting care when traveling or away from the plan's service area If you need care when you are outside the service area, your health care coverage is very limited. The only services we cover when you are outside our service area are care for a medical emergency, including maintenance care and hospital care after you are stable (known as post-stabilization care), urgently needed care, renal dialysis (kidney), and care that CCM Direct or a plan provider has approved in advance. For more information about medical emergency and urgently needed care, see Section 6. If you question whether a service is covered when you travel, please call Member Services at 1-877-226-8500. Can the list of plan providers change? Yes, CCM Direct may add or remove plan providers from our provider directory. To get current information about CCM Direct plan providers in your area, you can visit www.ccmny.org or call our Member Service Department at 1-877-226-8500, Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY users should call 1-800-650-2774. Your rights to access and participate in medical care You have the right to get timely access to plan providers and to all services covered by the plan. Timely access means that you can get appointments and services within a reasonable period of time. You have the right to get full information from your providers when you go for medical care. You have the right to participate fully in decisions about your health care. You have the right to refuse care. Section 2 - Choosing your Primary Care Physician (PCP)What is a "PCP"? When you become a member of CCM Direct, you must choose a plan provider to be your PCP. Your PCP is a physician who meets state requirements and is trained to give you basic medical care. You will get your routine or basic care from your PCP. Your PCP can also coordinate the rest of the covered services you need. In most cases, you must see your PCP to get a referral before you see any other health care provider. How do you choose a PCP? Finding a provider is easy. The directory is organized by Physician Providers and Non-Physician Providers. To find a physician, simply enter the physician sectionin the directory. Then search first by county and second by specialty, including primary care, for a physician. Non-Physician Providers are organized by county and then by category, for example, hospitals, laboratories, etc. If you do not see your current PCP in the directory, you may want to call your current PCP to see if he or she would recommend a physician listed in the directory. If you want to use a particular CCM Direct specialist or hospital, you should check with your PCP to make sure they can make referrals to that specialist or hospital. You may also get help from Member Services by calling 1-877-226-8500, Monday to Friday, from 8:00 a.m. to 5:00 p.m. TTY users should call 1-800-650-2774. You may change your PCP at any time. Simply call Member Services. Getting care from your PCP Generally, you see your PCP first for most of your routine health care needs. There are only a few types of covered services you can get on your own, without seeing your PCP first. Please see Section 4 for the type of covered services you can get on your own. Your PCP can help you arrange or coordinate your covered services. This includes x-rays, laboratory tests, therapies, specialists, hospital admissions, and follow-up care. Your PCP also contacts other plan providers for updates about your care and/or treatment. If you need certain types of covered services or supplies, your PCP must give approval ahead of time. This means you will need a referral to see a plan specialist. In some cases, your PCP will also need to get prior authorization (prior approval). Since your PCP will provide and coordinate your health care, you should have all of your past medical records sent to your new PCP’s office. The law requires us to protect your privacy of medical records and personal health information. For more information about privacy, see your Evidence of Coverage. How to change your PCP You may change your PCP for any reason, at any time. To change your PCP, call Member Services at 1-877-226-8500, Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY users should call 1-800-650-2774. When you call, be sure to tell Member Services if you are seeing specialists or getting other covered services that needed your PCP’s approval (such as home health services and durable medical equipment). Member Services will help make sure that you can continue with the specialty care and other services you have been getting when you change to a new PCP. They will also check that the PCP you wish to switch to is accepting new patients. Member Services will change your membership record to show the name of your new PCP, and will tell you when the change to your new PCP will take effect. What if your doctor or provider leaves CCM Direct? Sometimes a doctor, specialist, clinic, or other plan provider you are using might leave the plan. If this happens, you will have to switch to another provider who is part of CCM Direct. If your PCP leaves CCM Direct, we will let you know, and help you switch to another PCP so that you can continue getting covered services. Section 3 - Getting care from specialistsWhen your PCP thinks that you need specialized treatment, he or she will give you a “referral” (approval ahead of time) to see a plan specialist. A specialist is a doctor who provides health care services for a specific disease or part of the body. Some examples of specialists are oncologists, who treat cancer; cardiologists, who treat heart conditions; and orthopedists, who treat certain bone, joint, or muscle conditions. For some types of referrals to plan specialists, your PCP may need to get approval ahead of time from CCM Direct. This is called “prior authorization.” It is very important to get a referral from your PCP before you see a plan specialist. However, you don’t need to get a referral for certain services, see Section 4. If you don’t have a referral before you get services from a specialist, you may have to pay for these services yourself. If the specialist wants you to come back for follow-up visits, be sure to check the original referral to see if these were included. Each plan PCP has certain plan specialists they use for referrals. This means that the CCM Direct specialists you can use may depend on which person you chose to be your PCP. If there are specific specialists you want to use, find out whether your PCP refers patients to these specialists. You can change your PCP at any time if you want to see a plan specialist that your current PCP does not refer to. If you want to change your PCP, see Section 2. If there are specific hospitals you wish to use, find out whether your PCP uses these hospitals. Section 4 - Self-referralsThere are certain times when you may be able to get certain services without a referral. You will get most of your routine or basic care from your PCP. Your PCP can also coordinate your covered services. If you get services from any doctor, hospital, or other health care provider without getting a referral ahead of time from your PCP, you may have to pay for these services yourself. This also includes if you get these services from a provider in your plan. In some cases, you can get the services listed below without a referral or approval ahead of time from your PCP. "Self-referred" means you get services on your own. If you get self-referred services, you still have to pay a copayment. However, if you get a self-referred service from a plan provider, you will only have to pay the in-network copayment. If you go to a non-plan provider for these services, you will have to pay more. The following services may be self-referred:
Section 5 - What if you need medical care when your PCP's office is closed?What to do if you have a medical emergency or urgent need for care and your PCP's office is closed In an emergency, you can get care immediately. You do not have to contact your PCP or get prior authorization in an emergency. You can dial 911 for immediate help by phone, or go directly to the nearest emergency room, hospital, or urgent care center. For more information about emergency or urgent needed care, see Section 6. What to do if it is not a medical emergency and your PCP's office is closed If you need to talk with your PCP or get medical care when the PCP office is closed, and it is not a medical emergency, call your PCP phone number. There will always be a doctor on call to help you. Should you have difficulty reaching your PCP, call CCM Direct at 1-877-226-8500, 24 hours a day, 7 days a week; TTY users should call 1-800-650-2774. There will always be a health professional on call to help you. For more information about what to do if you have an urgent need for care, see Section 6. Section 6 - Getting care if you have a medical emergency or an urgent need for careWhat is a medical emergency? A situation is a "medical emergency" if you reasonably believe that your health is in serious danger. It means that every second counts. Some examples of "medical emergencies" are severe pain, a bad injury, a serious illness, or a medical condition that is getting worse. What should I do if I have a medical emergency? If you have a medical emergency:
CCM Direct will help manage and follow-up on your emergency care It is important to know that every emergency has two stages. When the doctors, or hospital, providing emergency care consider your condition stable, the first stage of the medical emergency ends. However, even after your condition is stabilized, you are still considered in an emergency situation and CCM Direct must still pay for post-stabilization treatment provided by the hospital (whether or not this hospital is a plan provider or not). This second stage of the emergency, after your condition is stabilized is call “post-stabilization.” Generally, the hospital, or doctors, providing emergency care will try to talk to your PCP. This helps the plan to arrange for plan providers to take over your care as soon as your condition and circumstances get better. Once your PCP takes over your care or agree with the attending hospital on an appropriate course of action (or once you are discharged if you are fully recovered), you are no longer in an emergency or post-stabilization situation. Although you are past the emergency and post-stabilization, you may still need follow-up care. However, your plan is responsible for your follow-up care. Your plan will only pay for followup care after your emergency and post-stabilization if you follow the plan rules. You will need to use plan providers to get authorization, and/or referrals. What is covered if I have a medical emergency?
What if it wasn't really a medical emergency? To have your plan pay for your emergency care, you do not have to be certain that it is an emergency. For example, you might go in for emergency care—thinking that your health is in serious danger—but the doctor may disagree and not consider this a medical emergency. If this happens, you are still covered for the diagnostic treatment and care you received to determine what was wrong, provided that you thought your health was in serious danger, as explained in the section “What is a ‘medical emergency’” above. However, please note that:
What is "urgently needed care"? (This is different from a medical emergency.) Urgently needed care refers to a non-emergency situation where you are inside the United States, you are temporarily absent from the Plan’s authorized service area, you need medical attention right away for an unforeseen illness, injury, or condition, and it isn’t reasonable given the situation for you to obtain medical care through the Medicare Advantage Plan’s participating provider network. Note: Under unusual and extraordinary circumstances, care may be considered urgently needed when the member is in the service area, but the provider network of the Plan is temporarily unavailable or inaccessible. What is the difference between a "medical emergency" and "urgently needed care"? The two main differences between urgently needed care and a medical emergency are in the danger to your health and your location. A “medical emergency” occurs when you reasonably believe that your health is in serious danger, whether you are in or outside of the service area. “Urgently needed care” is when you need medical help for an unforeseen illness, injury, or condition, but your health is not in serious danger and you are generally outside of the service area. Getting urgently needed care when you are in the plan's service area If you have a sudden illness or injury that is not a medical emergency, and you are in the plan’s service area, please call your PCP or call CCM Direct at 1-877-226-8500 for assistance contacting your PCP 24 hours a day, 7 days a week. There will always be a health professional on call to help you. Keep in mind that if you have an urgent need for care while you are in the plan’s service area, you should get this care from plan providers. In most cases, we will not pay for urgently needed care that you get from a non-plan provider while you are in the plan’s service area. Getting urgently needed care when you are outside the plan's service area CCM Direct covers urgently needed care that you get from non-plan providers when you are outside the plan’s service area but still in the United States. If you need urgent care while you are outside the plan’s service area, you should call your PCP. If you are treated for an urgent care condition while out of the service area, we prefer that you return to the service area to get follow-up care through your PCP. However, we will cover follow-up care that you get from non-plan providers outside the plan’s service area as long as the care you are getting still meets the “urgently needed care” definition. We also cover renal dialysis (kidney) services that you get when you are outside the plan's service area. Section 7 - For more informationFor more detailed information about your CCM Direct provider coverage, please review the Evidence of Coverage. If you have questions about CCM Direct please call our Member Service Department at 1-877-226-8500, Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY users should call 1-800-650-2774. Or, visit www.ccmny.org. Section 8 - List of Plan Providers
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CCM is an affiliate of The Beth Abraham Family of Health Services.
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