Doctors and hospitals are an important part of your healthy community. And our local and regional network is broad and continues to grow. This means more choices of physicians and hospitals who have met our credentialing requirements. In addition, eligible out-of-area members use the Coventry National Network, one of the largest provider networks in the country with more than 5,200 hospitals and 710,000 health care providers across the country.
Getting Primary Care
Members with an HMO or POS product must select a primary care provider (PCP) from our network. Each family member may have a different PCP. Members may change PCPs at any time by accessing our website or calling Customer Service.
Although PPO members are not required to select a PCP, we encourage all of our members, regardless of product, to establish a relationship with a PCP to assist with coordinating health care needs. PPO members are encouraged to call Customer Service to select a PCP. PCP referrals are not required for PPO members to see specialty care providers.
Getting Specialty Care
Members may see in-network specialists without referrals from their PCPs, whenever medically necessary. If a plan has an out-of-network benefit (e.g., PPO plans) members may see out-of-network specialists for medically necessary services at a higher out-of-pocket cost. Some specialty services and procedures may require prior authorization from Coventry Health Care. These include, but are not limited to, all substance abuse, mental health, physical therapy, speech therapy, and occupational therapy services.
Although it is not required to have a referral from a PCP in order to see an in-network specialist, members should keep their PCP informed of any care they receive from other physicians. If Coventry Health Care’s provider network does not have a specialist who can give you the care you need, your PCP can refer a member to an out-of-network specialist. HMO members need written approval from Coventry Health Care before seeing an out-of-network provider.
Members may find information on our in-network hospitals by searching Coventry Health Care’s online directory. HMO members must use in-network hospitals unless Coventry Health Care authorizes an out-of-network facility. Members with out-of-network benefits have much lower out-of-pocket expenses when choosing an in-network hospital. All hospital admissions, including observation, require prior authorization from Coventry Health Care. Although physicians usually obtain prior authorizations, it is ultimately the responsibility of members to make sure prior authorization is obtained before incurring expenses.
An emergency is the sudden start of a health problem that requires immediate medical attention. When determining whether a condition is a true emergency, members should consider what a prudent layperson with an average knowledge of health and medicine would consider an emergency. Members should call their PCPs, if possible, before going to the emergency room. It is important that physicians know when members receive emergency care.
Members should seek emergency care, even if they can not reach their PCP, for uncontrolled bleeding, chest pain or suspected heart attack, suspected or known poisoning, unconsciousness, broken bones, stroke or suspected stroke, seizures, convulsions, and severe injuries or burns. Members should consult their physician for routine or follow-up care for conditions such as flu, sore throat, and the removal of stitches.
Coventry Health Care recognizes that not all health situations occur at home. Members who travel, or students who reside outside Coventry Health Care’s service area, and become ill or injured are covered for emergency services at the in-network benefit level.
Members who reside outside Coventry Health Care’s service area may be eligible to obtain benefits at the in-network benefit level by seeing a Coventry National provider. Please contact Customer Service to see if you qualify to see a Coventry National provider.
Members who develop urgent health problems after office hours or on the weekend, should call their PCP, unless the health condition is an emergency. All Coventry Health Care in-network providers are committed to providing our members 24-hour coverage. This means they are available through an answering service or through the use of an on-call physician to handle urgent situations. If symptoms begin to develop during office hours, please contact your PCP to schedule an appointment.
- Pre-Authorization Requirements
- Learn more about services requiring prior authorization.
- Provider Directories
- Create a directory tailored to meet your needs.