About Your Care
We want to give you good care!
SWH of NY works with our providers to give you good health care. We look at your member benefits and make choices about care based on what you need. We want you to know:
- We do not reward providers to deny care.
- We do not reward staff or other people to deny care or give you less care.
- We do not pay extra money to providers or our staff members to deny tests or treatments that you need to get better or stay healthy.
Members who have a concern about their health care can call Member Services at 1-877-353-0185 (TTY 711) Monday through Friday, 8 a.m. to 8 p.m. There are nurses you can talk to 24/7 about your health care choices and getting the needed care. Call 1-877-353-0185.
If you have a PCP, they will take care of most of your needs. There will be times when you will need to see other type of doctors. These doctors are called specialists.
Examples of specialists are:
- Occupation Therapy
- Speech Therapy
- Physical Therapy
It is a good idea to check with Member Services to find out if a provider is part of SWH of NY. You might need a provider that is not part of SWH of NY. If this happens, call your PCP to get prior approval from SWH of NY.
Out of Network Services
If a SWH of NY provider is unable to provide a member with necessary and covered services, SWH of NY must cover the needed services through an out-of-network provider. This must be done in a timely manner for as long as SWH of NY is unable to provide the service.
After Hours Care
You might need to reach your provider after or before their office is open. If you do, you may call the number you usually reach them at. All providers have coverage for their patients 24 hours a day, 7 days a week. Your doctor may have an answering service where someone can help you with your medical issue or call the doctor. Sometimes your provider may have another provider cover for them either after hours or if your doctor is away. They could give you advice over the phone and sometimes prescribe a medication. You might be asked to visit the provider or be sent to an urgent care center.
SWH of NY has trained nurses available 24/7 at 1-877-353-0185. They can help you decide if you should see a provider right away. The nurses can also help you make an appointment if you need to see a provider quickly. Sometimes, you have questions, but you do not think you need to see your provider.
If you feel this is an emergency, call 911 or go to the nearest emergency room.
An Emergency is a medical problem that needs to be treated immediately. You do not have to call SWH of NY for approval in an emergency. Call 911 or go to the nearest emergency room. You can get emergency care 24 hours a day, 7 days a week.
Some examples of emergency are:
- Seizures or convulsions
- Unusual or excessive bleeding
- Severe pain
- Severe burns
- Trouble breathing
- Chest pains
Please carry your Member ID Card with you. If you are told you need to stay in the hospital, make sure the hospital calls SWH of NY. Once you leave the ER and are told you need further medical care, call your doctor. Do not go to the ER for follow-up care. Make an appointment with your doctor.
If you are not sure if you need emergency care, call your PCP or call SWH of NY at 1-877-353-0185. We have nurses available 24/7 to speak with you.
Hospital emergency rooms are only for real emergencies. These are not for non-emergency care. They are often very busy and must care first for those whose lives are in danger. Please do not go to a hospital emergency room if your condition is not an emergency.
Out of Area Care
If you are away from SWH of NY’s service areas and need emergency care, go to the nearest emergency room for care. Please contact us within 24 hours or as soon as you can. Call 1-877- 353-0185 (TTY 711). When you are away from SWH of NY’s service area, only emergency care is covered. *Out of area urgent care services require prior authorization. No services are covered outside the United States.
Urgent care services are for conditions that need attention right away. You should call your PCP for urgent care services. Your PCP may send you to an after-hours clinic or an urgent care center when the doctor’s office is closed.
Some examples of urgent services are:
- Minor injuries
- Minor illnesses
- High fever for children or elderly
- Simple fractures
- Eye injuries
- Insect bites
- COVID-19 symptoms*
An urgent care center is not an emergency room. If you are not sure if you need to go to the ER, call your PCP or SWH of NY Member Services at 1-877-353-0185. A nurse is available to speak with you 24/7. Your PCP or our nurses can help you decide what to do.
You or your doctor have the right to ask for a second opinion. You or your doctor can call Member Services to request the second opinion.
Reasons why second opinions are needed:
- You are not sure you need the treatment the doctor suggests
- You are not sure of the doctor’s diagnosis
- You have a complex problem
- Your doctor is not sure of a correct diagnosis
- You have complex symptoms
- You have followed the doctor’s care plan but have not improved
- You have talked with your doctor about your concerns but still are not satisfied
If a second opinion is approved, you will not have to pay for the services. The doctor that you see for a second opinion will send a written report to you and your PCP.
SWH of NY may decide a second opinion is not needed. If so, we will send you a denial letter with your appeal rights.
If you prefer to speak in your own language, Member Services can help. An interpreter will be available to speak with you. They can also help you speak to the doctor. An interpreter can help you:
- Make an appointment.
- Talk with your doctor or nurse.
- Get emergency care.
- File a complaint, grievance, or appeal.
- Get help from a pharmacist about taking medicine.
Interpreter services are free to all members. To ask for an interpreter, call Member Services at 1-877- 353-0185 (TTY 711). If you have an appointment, your doctor can help you find an interpreter.