• An emergency room doctor recently treated my daughter for a broken arm and tooth. Both resulted from an accidental fall. The ER doctor recommended follow-up treatment with a doctor not in the HMO network. My HMO plan denied payment for the charges, because I did not have a referral from her PCP. What should I have done?
• Do I need to add my newborn as a dependent or will she be added automatically?

Q: An emergency room doctor recently treated my daughter for a broken arm and tooth. Both resulted from an accidental fall. The ER doctor recommended follow-up treatment with a doctor not in the HMO network. My HMO plan denied payment for the charges, because I did not have a referral from her PCP. What should I have done?

A: After the ER doctor treated your child’s wounds and she was no longer in an emergency situation, you should have contacted her primary care physician. Her PCP would have evaluated her condition, determined a course of treatment, and would have made a referral to an appropriate doctor or dentist. The HMO plan covers some dental procedures when natural teeth are damaged during an accident, treatment is sought within 72 hours of the accident, and dental treatment is completed within 24 months after the accident. Remember, it is your responsibility to verify that a physician is in the HMO network.

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Q: Do I need to add my newborn as a dependent or will she be added automatically?

A: New dependents, including newborns, must be added to your benefits plans within 31 days. Dependents added after 31 days become covered on the 1st or 16th of the month after a 90-day waiting period. The benefits plans will not pay expenses for medical, dental or life insurance claims incurred during the waiting period.

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