There are two Heritage Select plan models: A Primary Care model and an Open Access model. The Primary Care model requires a member to see a Primary Care Physician (PCP) as the starting point for all health care, unless an emergency situation arises. The member is not required to register a PCP selection and may see a different PCP without notifying UnitedHealthcare.
In the Open Access model (also known as a Split Copayment plan) a member may go to any network provider but will have two different copayment amounts: one for a visit to a PCP (family practice, internal medicine, or pediatric physician), and a higher copayment for a visit to a specialist. If you are unsure whether or not you have an Open Access plan, check the front of your member ID card. A split copayment is indicated by two copayment amounts for office visits (e.g., $15P/25S).*
In the Primary Care model, when a member receives treatment from a PCP selected from our network of primary care providers, the PCP acts as the member’s health care advocate and resource, recommending health care services and other physicians when necessary. If a PCP is not able to treat a member’s condition, the PCP will refer him or her to a specialist.
In the Primary Care model, a member must obtain a referral from a PCP to receive services from other in-network providers. However, a member of an Open Access model (Split Copayment plan), does not have to choose a PCP or obtain a referral to see a network provider. Under a split copayment plan, there is a higher office visit copayment for specialists compared to PCPs.
When a PCP makes a referral, it is usually to a specialist in our network of contracted providers. But it is always a good idea for the member to make sure that specialist is in our network. In addition to a printed Provider Directory, members can use our online Provider Directory or call the Customer Service number on the back of their ID card.
NOTE: Female plan members can see a network obstetrician/gynecologist for their annual exam or obstetrical care without a referral from their PCP.
Whenever members need to access health care for non-emergency services, they should consult with a PCP to help determine the best care or course of treatment.
Some Heritage Select plans may have a Point-of-Service (POS) option. Refer to your ID card to see if POS is listed.
* Members of the State of Tennessee Group Insurance Program are in the Primary Care model even though a split copayment is on their cards.