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Medical Care and Plan Providers
Your Medical Care
This page includes some basic information about how to get your covered services with Essence. To get more detailed information about your health care coverage, please see your Evidence of Coverage.
You will have to choose one of our plan providers that are listed in the Provider Directory to be your Primary Care Physician (PCP). Generally, you must get your health care coverage from your PCP.
The "plan providers" listed in the Provider Directory have agreed to provide you with your health care coverage. In most cases, your health care coverage is covered under Essence. You may go to any of our plan providers listed in the 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.
How do I find Essence providers in my service area?
The service area for our plans includes Snohomish County, WA and King County, WA. Both Primary Care Physicians and Specialists are listed in the Provider Directory by state, then by county. They are also listed alphabetically in the back of the directory.
Access2care
Essence offers its members limited transportation assistance to and from covered benefit appointments. For more information about this service, call Access2care at 877-889-2111.
Getting Care from your PCP
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. Your PCP must give you a referral to see a specialist. In some cases, your PCP will 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.
What if I use non-plan providers to get my covered services?
"Non-plan providers" are providers that are not part of Essence. 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, and any services which were covered through an appeals process.
What should I do if I have bills from non-plan providers that I think should be paid by Essence?
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 that you get when you are outside the plan's service area, care that has been approved in advance by Essence 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 the numbers listed below.
While Essence does not contract with specialists who provide certain services at a health care facility (such as anesthesiologists and pathologists), we do pay the facility for the cost of these services when provided at an in-network facility. If you receive a bill for such services, please contact Essence.
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 if it meets the criteria noted above and will let you know what, if anything, you must pay.