is not an emergency. Examples include, but are not limited to minor injuries, wounds, and cuts needing stiches; minor breathing issues; minor stomach pain. If you are unsure whether urgent care is your best option, call the consulting nurse helpline for advice at 1-800-297-6877 or 206-630-2244. If you need Emergency care while traveling and are admitted to a non-network hospital, you or a family member must notify us within 24 hours after care begins, or as soon as is reasonably possible. Call the notification line listed on the back of your KFHPWA Member ID card to help make sure your claim is accepted. Keep receipts and other paperwork from non-network care. You’ll need to submit them with any claims for reimbursement after returning from travel. Access to non-Emergency care across the Core network service area: your Plan provides access to all providers in the Core Network, including many physicians and services at Kaiser Permanente medical facilities and Core Network facilities across the state. Find links to providers at www.kp.org/wa/directory or contact Member Services at -1-866-648-1928 for assistance. 6. Urgent Care. Inside the KFHPWA Service Area, urgent care is covered at a Kaiser Permanente medical center, Kaiser Permanente urgent care center or Network Provider’s office. Outside the KFHPWA Service Area, urgent care is covered at any medical facility. Refer to Section IV. for more information about urgent care. For urgent care during office hours, you can call your personal physician’s office first to see if you can get a same-day appointment. If a physician is not available or it is after office hours, you may speak with a licensed care provider anytime at 1-800-297-6877 or 206-630-2244. You may also check www.kp.org/wa/directory or call Member Services to find the nearest urgent care facility in your network. 7. Women’s Health Care Direct Access Providers. Female Enrollees may see a general and family practitioner, physician’s assistant, gynecologist, certified nurse midwife, licensed midwife, doctor of osteopathy, pediatrician, obstetrician or advance registered nurse practitioner who is unrestricted in your KFHPWA Network to provide women’s health care services directly, without Preauthorization, for Medically Necessary maternity care, covered reproductive health services, preventive services (well care) and general examinations, gynecological care and follow-up visits for the above services. Women’s health care services are covered as if the Enrollee’s Network Personal Physician had been consulted, subject to any applicable Cost Shares. If the Enrollee’s women’s health care provider diagnoses a condition that requires other specialists or hospitalization, the Enrollee or her chosen provider must obtain Preauthorization in accordance with applicable KFHPWA requirements. For a list of KFHPWA providers, contact Member Services or view the Provider Directory located at www.kp.org/wa. 8. Travel Advisory Services. Our Travel Advisory Service offers recommendations tailored to your travel outside the United States. Nurses certified in travel health will advise you on any vaccines or medications you need based on your destination, activities, and medical history. The consultation is not a covered benefit and there is a fee for a KFHPWA Enrollee using the service for the first time. Travel-related vaccinations and medications are usually not covered. Visit www.kp.org/wa/travel-service for more details. 9. Process for Medical Necessity Determination. Pre-service, concurrent or post-service reviews may be conducted. Once a service has been reviewed, additional reviews may be conducted. Enrollees will be notified in writing when a determination has been made. First Level Review: First level reviews are performed or overseen by appropriate clinical staff using KFHPWA approved clinical review criteria. Data sources for the review include, but are not limited to, referral forms, admission request forms, the Enrollee’s medical record, and consultation with qualified health professionals and multidisciplinary health care team members. The clinical information used in the review may include treatment summaries, problem lists, specialty evaluations, laboratory and x-ray results, and rehabilitation PEBB HMOHSA 2024 8