CALIFORNIA - Pacificare Health Systems

professional applies the applicable criteria, including,
but not limited to:
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n
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Nationally published guidelines for utilization
management (specific guideline information
available upon request);
HCIA-Sachs Length of Stay © Guidelines (average
length of Hospital stays by medical or surgical
diagnoses);
Medical Management Guidelines (MMG) and
Benefit Interpretation Policies (BIP).
Those cases that meet the criteria for coverage and
level of service are approved as requested. Those not
meeting the utilization criteria are referred for review
to a Participating Medical Group’s Medical Director or
a PacifiCare Medical Director.
Denial, delay or modification of health care services
based on Medical Necessity must be made by a licensed
Physician or a licensed health care professional who
is competent to evaluate the specific clinical issues
involved in the health care services requested by the
Provider.
Denials may be made for administrative reasons that
include, but are not limited to, the fact that the patient
is not a PacifiCare Member or that the service being
requested is not a benefit provided by the Member’s
plan.
Preauthorization determinations are made once
the Member’s Participating Medical Group Medical
Director or designee receives all reasonably necessary
medical information. PacifiCare makes timely and
appropriate initial determinations based on the nature
of the Member’s medical condition in compliance with
state and federal requirements.
What To Do If You Have a Problem
PacifiCare’s top priority is meeting our Members’
needs, but sometimes you may have an unexpected
problem. When this happens, your first step should be
to call our Customer Service department. We’ll assist
you and attempt to find a solution to your situation.
If you have a concern about your treatment or a
decision regarding your medical care, you may be able
to request a second medical opinion. You can read
more about requesting, as well as the requirements for
obtaining a second opinion, in Section 2. Seeing the
Doctor.
Overseeing Your Health Care
If you feel that we haven’t assisted you or that your
situation requires additional action, you may also
request a formal Appeal or Quality Review. To learn
more about this, read the following section, “Appealing
a Health Care Decision.”
Appealing a Health Care Decision
Our appeals and quality of care review procedures are
designed to deliver a timely response and resolution to
your complaints. This is done through a process that
includes a thorough and appropriate investigation, as
well as an evaluation of the complaint. You may submit
a formal appeal within 180 calendar days of your
receipt of an initial determination through our Appeals
department.
To initiate an appeal or quality of care review, call our
Customer Service department at 1-800-624-8822, where
a Customer Service representative will document your
appeal or write the Appeals department at:
PacifiCare of California
Appeals Department
Mail Stop CY422-294A
5701 Katella Avenue
P.O. Box 6006
Cypress, CA 90630
This written request will initiate the following Appeals
Process except in the case of “expedited reviews,” as
discussed below. You may submit written comments,
documents, records and any other information
relating to your appeal regardless of whether this
information was submitted or considered in the initial
determination. You may obtain, upon request and free
of charge, copies of all documents, records and other
information relevant to your appeal. The appeal will be
reviewed by an individual who is neither the individual
who made the initial determination that is the subject
of the appeal nor the subordinate of that person.
PacifiCare will review your appeal and if the appeal
involves a clinical issue, the necessity of treatment
or the type of treatment or level of care proposed or
utilized, the determination will be made by a medical
reviewer who has the education, training and relevant
expertise in the field of medicine necessary to evaluate
the specific clinical issues that serve as the basis of your
appeal.
Questions? Call the Customer Service Department at 1-800-624-8822. 113
PART A