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Get the Most from Your Coverage

You Deserve Quality Healthcare. And you also deserve to have the information you need to get the most from your coverage. Goals for quality are set and reviewed by MHS Health Wisconsin to make sure you get the care you need.

This information is part of a Quality Program designed to improve the services and care you receive. It provides details about your coverage and services available to you. 

Contact Member Services to learn more about the Quality Program.

Know Your Rights

Being a member means there are things you should expect from your health plan. These are some of your rights:

  • You should have access to all the services available to members
  • You should be treated with courtesy and respect
  • You should be able to get a copy of your medical record
  • You should know your medical data will be kept private. There are policies in place to guard your health records and protected health information.

It’s also important to know what you can do to get the most from your coverage:

  • Ask questions if you don’t understand your rights
  • Be sure to keep your scheduled appointments
  • Keep your Member ID Card with you so you have it at appointments
  • Tell your doctor if you have gotten care in an emergency room.

The full list of rights and responsibilities is in your Member Handbook.

Getting the Care You Need

Your PCP is the doctor you’ll see for routine checkups and care. Your PCP will help find other types of healthcare providers if you need one. 

Search for a provider, hospital, or clinic 

As children get older, they should change from seeing a pediatrician to seeing an adult doctor. Teens don’t need checkups as often as young kids do, but they should see their PCP at least once a year. Regular visits will help them stay up to date on vaccines. If teens have a condition such as diabetes or asthma, it’s very important that they keep seeing their doctors and not miss a visit. Call your health plan if you need help finding an adult provider.

Visit our Children's Health page for more information

You should be able to schedule an appointment with your PCP and get medical care when you need it. You may have to wait a little longer to get in to see certain other types of providers, like specialists. Call your health plan if you can’t get an appointment in a timely manner.

Primary Care

Type of CareAppointment Timeframe
EmergencyImmediately upon request of an appointment
Urgent CareWithin 48 hours of request of an appointment
Non-urgent, Symptom CareWithin 7 calendar days of request of an appointment

Routine

Within 30 calendar days of request of appointment


Specialty Care

Type of CareAppointment Timeframe

Routine

Within 60 calendar days of request


OB/GYN and Maternity Care

Type of CareAppointment Timeframe

First trimester

Within 30 days of request

Second trimester

Within 30 days of request

Third trimester

Within 30 days of request

High risk pregnancies

Within 2 weeks of request for an appointment, or within three weeks if the request is for a specific HMO provider, who is accepting new patients.


Dental Care

Type of CareAppointment Timeframe

Emergency

Within 24 hours of request

Urgent Care

Within 72 hours of request

Routine

Within 36 business days from request


Behavioral Health Care

Type of CareAppointment Timeframe

Initial Routine Care

Within 10 days

Urgent

Within 48 hours for non-emergent urgent services

Emergent/Non-life threatening

Within 6 hours of a request on a 24-hour basis, seven days a week

Follow up routine care

Within 10 business days

Follow up after an inpatient mental health stay

Follow-up post discharge appointments are to be within seven days or no longer than 30 days for an appointment with a Mental Health Provider for follow-up after an inpatient mental health stay

Non-Psychiatric (non-prescriber)

Within 30 days

Psychiatric (prescriber)

Within 90 days

You should get high quality medications and the right treatment for your conditions. But not all drugs are covered. And some may need to be approved before they’re covered.

Talk to your doctor or pharmacist to review the PDL and answer questions about your medications.

You can find the Preferred Drug List (PDL) on the ForwardHealth website. It is updated regularly and lists drugs that are covered by insurance.

The Utilization Management (UM) Department looks at your health records and may also talk with your doctor to decide if a service you need is covered. These decisions are not based on financial reasons. And doctors and staff are not rewarded for saying no to care. All UM decisions are based on:

  • If the service is medically necessary
  • If the service works well
  • If the service is right for you

New medicines, tests and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by your health plan. Your plan covers care that is medically necessary. Not every new medical service is covered for all members.

If a service is denied, you have the right to appeal that decision. You will be sent a letter explaining how to make an appeal. All appeal requests are decided according to your request, condition and benefits.

Care Management is for members who may need extra help taking care of their health. Some people have several health conditions and see more than one doctor. Others need help arranging the services their doctors may have ordered. Working with a care manager lets you understand major health problems, work well with your doctors and get the care you need.

There are several care options depending on your symptoms. Most minor illnesses do not need emergency care. They can be treated by your own provider or an urgent care clinic.

Your primary care provider (PCP)

  • You can schedule an appointment with your primary doctor if you are sick but it’s not an emergency. Many/most clinics have same-day or next-day open “sick appointment” time slots in their schedules.
  • For most health problems, you should call your doctor. Your doctor knows about your health and can give you the best care for ongoing problems, such as asthma, diabetes, or sickle cell anemia.
  • If your illness or injury problem is not serious, you may wait a long time in urgent care or the emergency room.


Urgent care

  • If you can’t wait to see your doctor but it’s not an emergency, you can visit a walk-in clinic or urgent care center.
  • MHS Health has more than 70 walk-in/urgent care clinics in our network.
    • Call the MHS Health 24-hour nurse advice line at 1-800-280-2348.
    • Call the MHS Health Customer Service line at 1-888-713-6180.

For a complete listing of urgent care and walk-in clinics in our network, visit our Find a Provider online directory.


Emergency room

  • Emergency rooms (ERs) are open 24 hours a day. You should call 911 or go to the nearest emergency room if you think your child’s life is in danger or they could be permanently hurt or disabled without care. The ER can provide help quickly to prevent permanent injury or death.
  • Still don’t know if you should go to the emergency room? Call your doctor or our 24-hour nurse advice line at 1-800-280-2348 before you go to the emergency room.
  • Call your doctor to let them know you are in the emergency room whenever it is safe for you to do so.
  • Call MHS Health at 1-888-713-6180 as soon as you can to tell us what happened.


Guide for choosing between urgent care and emergency care 

EMERGENCY

NON-EMERGENCY

Call 911 or go to the nearest emergency room for the following illnesses or injuries. These are problems that generally do not need emergency help.

Bleeding that won’t stop

Diarrhea

A broken bone

Throwing up

Chest pain or other severe pain

A cut or scrape

A bad burn

An earache

Poisoning

A sore throat

Seizures

A cough or cold

Shock (sweaty, thirsty, pale skin)

Diaper rash

Fainting/unconsciousness

Sexually transmitted disease (STD)

You are in labor

You need refills of medicines

Gun or knife wounds

Mild headache

Drug overdose

Lice, scabies, or ringworm

Suddenly not able to move or speak

 

If you still don’t know where to go for care:

  • In someone's life is in danger, call 911 or go to the nearest emergency room.
  • Call your child’s doctor. They should have a 24-hour emergency answering service.
  • Call the MHS Health 24-hour nurse advice line at 1-800-280-2348.


Suicide and Crisis Help

  • Call 911 or go to the nearest emergency room if you think your or someone’s life may be in danger.
  • The Suicide and Crisis Lifeline provides 24/7, free and confidential support for people in distress, prevention, and crisis resources

Just call 9-8-8


MHS Health 24-hour Nurse Advice Line

  • Our nurse advice line provides free 24-hour medical advice, 7 days a week. Call 1-800-280-2348.
  • The nurse advice line has registered nurses ready to talk with you when you can’t reach your doctor.
  • Our nurses speak English and Spanish. They can answer your questions and help you.
    • For example, if your child has a fever, cough, or cold symptoms, you can call the nurse advice line for help deciding what you can do to help them.


MHS Health Appointment Unit

  • MHS Health can help you make or change an appointment with a provider. We can even help you find transportation to and from your appointment. Call 1-844-908-0681, Monday – Friday, 8 a.m. – 6 p.m., CST.

BEFORE the appointment

  • Find out their policy for canceling or rescheduling an appointment.
  • Ask for an interpreter to be present at your appointment if you need one.
    • MHS Health offers interpreters at no cost to you. Call us if you need help finding an interpreter. 1-888-713-6180.
    • You should not use children, friends, and family as interpreters.
  • Coordinate how you will get to and from your appointment.
  • Prepare questions that you want to ask your doctor. Write down any questions you have before you go and bring them to the appointment.
  • Make plans to arrive early. Getting to the clinic about 15 minutes before the appointment will give you time to fill out paperwork and just relax.
  • Ask a friend or family member to go with you. Feeling nervous is normal. Bringing a friend can help you relax. They can also help you remember questions to ask and instructions you may receive.
  • Know your health history. Your doctor may ask you questions about your health and the health of your family. Asking these questions helps your doctor learn more about you.
  • Things to bring to your appointment
    • Your ForwardHealth member ID card
    • List of medications you are taking. You can also put all your medications in a bag and bring them with you.
    • Include all prescriptions, vitamins, supplements, and any medications you can buy without a prescription (over-the-counter)
      • Examples include acetaminophen, ibuprofen, antacids, allergy medicines,
  • Your prepared questions. 


DURING the appointment

  • Make sure the clinic office has your correct contact information (phone, address, email)
  • Ask your questions. Make sure your doctor knows that you have some questions to ask.
  • Take notes. Write down the answers to your questions. You can ask for paper and a pen.
  • Make sure you understand any directions given to you before you leave. Repeat them back to ensure you heard them correctly.
  • Be honest. Your doctor can help you with your health and any support you may need.
  • Ask questions. Questions or concerns about a medication or a test or procedure are easier asked in person. If you forget, call your doctor’s office right away to get the answer you need.
    • Ask for language assistance if you need it. MHS Health offers interpreters at no cost to you.
    • You should not use children, friends, and family as interpreters.
  • Understand why your doctor and staff are typing on the computer.
    • Your provider keeps your medical information in an electronic medical record (EMR).
    • About the EMR
      • Your EMR includes appointment notes, tests and results, your medication list, and more.
      • The EMR also is helpful for you, too.
        • Review test results
        • Ask questions of your doctor
        • Request prescription refills
        • Look up upcoming appointments
      • If you are not signed up to access your EMR, ask your provider or the clinic staff to help get you set up.


AFTER the appointment

  • Before you leave the exam room, ask to review the After-Visit Summary
    • As part of the Affordable Care Act, the Centers for Medicaid Services (CMS) recommend physicians provide patients with an After-Visit Summary (AVS) following a clinic visit. It may also be called a Summary of Care.
    • An AVS is a paper or electronic document given to patients at the end of a medical appointment.
    • An AVS includes
      • An overview of what was talked about and done during the appointment
      • Care plan goals and instructions
      • List of chronic conditions
      • List of current medications and refills
      • Vital signs
      • Lab tests and results
      • Future appointments and tests
      • Referrals to other providers
  • If you have questions after you leave the appointment, call your doctor.

Having a healthy pregnancy can lead to a healthy birth. Getting early and regular prenatal care improves the chances of a healthy pregnancy.

This care can begin even before pregnancy with a pre-pregnancy care visit to your provider. Pre-Pregnancy and prenatal care can help prevent complications and inform parents about important steps they can take to protect their infant and ensure a healthy pregnancy. 

Visit our Pregnancy Services page.

Start Smart for Your Baby® 

Start Smart for Your Baby (Start Smart) is our special program for women who are pregnant and postpartum. We want to help you take care of yourself and your child throughout your pregnancy. Our Start Smart staff can answer questions and give you support if you are having a problem. This program focuses on your health during your pregnancy and your baby’s first year. We can even arrange for a home visit, if needed. Start Smart for Your Baby® offers many benefits at no cost to you.

Visit the Start Smart for Your Baby page for more information.


My Health Pays Rewards

You can even earn My Health Pays rewards for healthy behaviors during and after pregnancy!

Get More Information

Your Member Handbook is a great source for information about your coverage and benefits. It also lists important phone numbers.

 

Call: You can also contact Member Services for additional help at 1-888-713-6180. Translation services are available if you need them.

Member Services to get:

  • A paper copy of your Member Handbook, Privacy Notice or anything on your health plan website
  • Help finding a doctor and making an appointment
  • Help speaking with a care manager
  • Help with an appeal for a service that’s been denied
  • Help with a ride to your appointment

 

Your health plan website also has a lot of helpful information. Visit it to find the Member Handbook, Find-a-Provider tool, and the Preferred Drug List. You can also use it to help you manage your health.

 

Creating an online member account is free and easy. With it, you can:

  • Find or change your PCP
  • Request a new Member ID Card or print a temporary ID Card
  • View and update your personal information

You can also send a message directly to your health plan from your member account.