CALIFORNIA - Pacificare Health Systems

Section 9. Overseeing Your Health Care
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How PacifiCare Makes Important Decisions
New Treatments and Technologies
What To Do If You Have a Problem
Quality of Care Review
Appeals and Grievances
Independent Medical Reviews
How PacifiCare Makes Important Health Care
Decisions
This section explains how PacifiCare authorizes or
makes changes to your health care services, how we
evaluate new health care technologies and how we
reach decisions about your coverage.
You will also find out what to do if you’re having a
problem with your health care plan, including how
to appeal a health care decision by PacifiCare or one
of our Participating Providers. You’ll learn the process
that’s available for filing a formal grievance, as well
as how to request an expedited decision when your
condition requires a quicker review.
Authorization, Modification and Denial of
Health Care Services
PacifiCare and its Participating Medical Groups use
processes to review, approve, modify or deny, based
on Medical Necessity, requests by Providers for
authorization of the provision of health care services to
Members.
PacifiCare and Participating Medical Groups may
also use criteria or guidelines to determine whether
to approve, modify or deny, based on Medical
Necessity, requests by Providers of health care services
for Members. The criteria used to modify or deny
requested health care services in specific cases will be
provided free of charge to the Provider, the Member
and the public upon request.
Decisions to deny or modify requests for authorization
of health care services for a Member, based on Medical
Necessity, are made only by licensed Physicians or
other appropriately licensed health care professionals.
Member agrees that their Provider will be their
“authorized representative” (pursuant to ERISA)
regarding receipt of approvals of requests for health
care services for purposes of medical management.
Overseeing Your Health Care
PacifiCare and Participating Medical Groups make these
decisions within at least the following time frames
required by state law:
Decisions to approve, modify or deny requests
for authorization of health care services, based on
Medical Necessity, will be made in a timely fashion
appropriate for the nature of the Member’s condition,
not to exceed five (5) business days from PacifiCare’s
or the Participating Medical Group’s receipt of the
information reasonably necessary and requested to
make the decision.
If the Member’s condition poses an imminent and
serious threat to their health, including, but not limited
to, potential loss of life, limb or other major bodily
function, or if lack of timeliness would be detrimental
in regaining maximum function or to the Member’s
life or health, the decision will be rendered in a timely
fashion appropriate for the nature of the Member’s
condition, not to exceed 72 hours after PacifiCare’s
or the Participating Medical Group’s receipt of the
information reasonably necessary and requested by
PacifiCare or the Participating Medical Group to make
the determination (an “Urgent Request”).
If the decision cannot be made within these time
frames because (i) PacifiCare or the Participating
Medical Group is not in receipt of all of the
information reasonably necessary and requested or (ii)
PacifiCare or the Participating Medical Group requires
consultation by an expert reviewer or (iii) PacifiCare
or the Participating Medical Group has asked that an
additional examination or test be performed upon
the Member, provided the examination or test is
reasonable and consistent with good medical practice,
PacifiCare or the Participating Medical Group will
notify the Provider and the Member, in writing, upon
the earlier of the expiration of the required time frames
above or as soon as the plan becomes aware that it will
not be able to meet the required time frames.
The notification will specify the information requested
but not received or the additional examinations or tests
required and the anticipated date on which a decision
may be rendered following receipt of all reasonably
necessary requested information. Upon receipt of
all information reasonably necessary and requested
by PacifiCare or the Participating Medical Group,
PacifiCare or the Participating Medical Group shall
approve, modify or deny the request for authorization
within the time frames specified above as applicable.
Questions? Call the Customer Service Department at 1-800-624-8822. 111
PART A