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Medi-Cal Member Handbook / Benefit Year 2006-2007(okay) a second opinion by a qualifiedprovider outside the network.3. Call the second opinion doctor to make anappointment.4. Show the doctor’s office your ID card.You may complain if your health plan deniesyour request for a second opinion or you do notagree with the second opinion. This is also called“filing a grievance.” This is talked about in“Complaints: What do I do if I am unhappy?” inthis handbook.Are you pregnant? Call CommunityHealth Plan at 1-800-475-5550Call your health plan right away if you arepregnant or become pregnant. This is because wewant you and your baby to be healthy. When youare pregnant, it is important to get care right awayand throughout your pregnancy.How to get health care that your PCPdoctor can’t give youSometimes you need care your PCP doctor can’tgive you. If you need care from a specialist, yourPCP doctor must okay (authorize) these servicesbefore you receive them. This is called a “referral.”A referral is when you request health careservices your PCP doctor does not normallyprovide.Routine referrals take up to five working days(“working days” are Monday through Friday).Expedited (rush) referrals may not take more thanthree working days. Please call CommunityHealth Plan if you do not get a response by thesetimes.Emergency services anywhere or urgently neededservices when outside of Los Angeles County donot need a referral.How to get a standing referral with aspecialistYou may need to see a specialist (or other appropriatelyqualified health care professional) for along time if you have a chronic (a long-termcondition like diabetes or asthma), lifethreatening(such as HIV/AIDS) or disablingcondition or disease.This is called a “standing referral.” A standingreferral is made to a specialist who is inCommunity Health Plan’s network or who is witha contracted specialty care center. If CommunityHealth Plan does not have a qualified specialist,Community Health Plan will send you to aspecialist outside their network. Once you have astanding referral, you will not need permissionfor each visit with the specialist.A standing referral needs an approval byCommunity Health Plan. You can ask your PCPdoctor for a standing referral. Or, your doctor canask Community Health Plan for a standingreferral. Community Health Plan must decide onyour request for a standing referral within threebusiness days.Your specialist will develop a treatment plan foryou if needed. The treatment plan will show howoften you need to go to the doctor. Once thetreatment plan is approved, the specialist willcoordinate the care you get. This specialist will beauthorized to provide health care services thesame way your PCP doctor would, based onexpertise, training and the treatment plan.7Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273
Medi-Cal Member Handbook / Benefit Year 2006-2007Our Provider Network:Who gives me health care?Please read the following information so you willknow from whom or what group of providers youcan get health care.Community Health Plan works with a large groupof doctors, specialists, pharmacies, hospitals andother health care providers. This group is called a“network.” You can get a copy of CommunityHealth Plan’s network by calling CommunityHealth Plan and asking for a provider directory.In most cases, you need to get care withinCommunity Health Plan’s network. That is notthe case if you need emergency care or needurgent care outside of Los Angeles County. Thisis talked about more in the section “EmergencyCare: How Do I Get Care in an Emergency?” inthis handbook.Your PCP doctor gives you most of your careYour PCP doctor is responsible for making sureyou get the health care benefits you need and areentitled to from Medi-Cal.How to change your PCP doctorIf you didn’t choose a PCP doctor when youenrolled in Medi-Cal, a PCP doctor was chosenfor you by L.A. Care. Your PCP doctor waschosen for you based on:• the language you speak• your age• how close you live to the PCP doctor’s officeIt is best to keep the same PCP doctor. Your PCPdoctor gets to know your health history andhealth needs. But sometimes you cannot stay withyour PCP doctor. You can choose a PCP doctorfrom the Community Health Plan network shownin the provider directory mailed to you with thishandbook. Call Community Health Plan foranother copy of the provider directory or to helpyou choose another PCP doctor.You can change your PCP doctor for anyreason if you are not happy. To change yourPCP doctor, call Community Health Plan. Youmay choose a PCP doctor within the first 30calendar days of enrollment and change atleast monthly after that.Things to remember if you choose a new PCPdoctor:• Some doctors work within a group of doctorswith certain specialists, hospitals and otherhealth care providers. If you need a specialist,your PCP doctor may send you to these providers.If you are going to a specialist alreadyor want to use a specific hospital, talk with thePCP doctor you are choosing.• A PCP is a doctor or even a clinic. You canpick one PCP doctor for all members of yourfamily in Medi-Cal. Or, you can pick a differentPCP doctor for each member of yourfamily in Medi-Cal. Women may choose anOb/Gyn or family planning clinic as their PCPdoctor.• Ask about office access if you or a familymember has a disability.The PCP doctor you choose may not agree totreat you and may ask L.A. Care to make achange. This can happen if:• you are disruptive or disrespectful to yourdoctor or your doctor’s office staff; or• you do not follow your doctor’s treatmentplan; or• the service or care you need are not within thedoctor’s scope of care (like a high-risk pregnancy)8Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273
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