CALIFORNIA - Pacificare Health Systems

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Licensed in the in State of California;
Certified by Medicare as a transplant facility for a
specific organ transplant;
Designated by PacifiCare as a transplant facility for a
specific organ program;
Able to meet the reasonable access standards
for organ transplantation based on the Regional
Organ Procurement Agency statistics within the
transplant Facility’s geographic location. A Regional
Organ Procurement Agency is a geographic area
designated by a state-licensed organ procurement
organization for transplants in the State of
California.
Non-Participating Providers – A Hospital or other
health care entity, a Physician or other health care
professional, or a health care vendor that has not
entered into a written agreement to provide Covered
Services to PacifiCare’s Members.
Non-Physician Health Care Practitioners – Include,
but are not limited to, psychologists, acupuncturists,
optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists
and nurse midwives.
Open Enrollment Period – The time period
determined by PacifiCare and the University of
California when all eligible employees and their
eligible Family Members may enroll in PacifiCare.
PacifiCare-Designated Pharmacy – PacifiCare
participating pharmacy designated to dispense
injectable medications. A PacifiCare-Designated
Pharmacy may include Prescription Solutions ® mail
service pharmacy or alternative specialty injectable
vendor as determined by PacifiCare.
Participating Hospital – Any general acute care
Hospital licensed by the State of California that has
entered into a written agreement with PacifiCare to
provide Hospital Services to PacifiCare’s Members.
Participating Medical Group – An independent
practice association (IPA) or medical group of
Physicians that has entered into a written agreement
with PacifiCare to provide Physician services
to PacifiCare’s Members. An IPA contracts with
independent contractor Physicians who work at
different office sites. A medical group employs
Physicians who typically all work at one or several
Definitions
physical locations. Under certain circumstances,
PacifiCare may also serve as the Member’s Participating
Medical Group. This includes, but is not limited to,
when the Member’s Primary Care Physician contracts
directly with PacifiCare and there is no Participating
Medical Group.
Participating Provider – A Hospital or other health
care entity, a Physician or other health care professional
or a health care vendor that has entered into a written
agreement to provide Covered Services to PacifiCare’s
Members. A Participating Provider may contract directly
with PacifiCare, with a Participating Medical Group or
with another Participating Provider.
Physician – Any licensed allopathic or osteopathic
Physician.
Prevailing Rates – As determined by PacifiCare, the
usual, customary and reasonable rates for a particular
health care service in the Service Area.
Primary Care Physician – A Participating Provider
who is a Physician trained in internal medicine,
general practice, family practice, pediatrics or
obstetrics/gynecology and who has accepted primary
responsibility for coordinating a Member’s health care
services.
Primary Residence – The home or address where the
Member actually lives most of the time. A residence
will no longer be considered a Primary Residence
if: (1) the Member moves without intent to return;
(2) the Member is absent from the residence for 90
consecutive days; or (3) the Member is absent from
the residence for more than 100 days in any six-month
period.
Primary Workplace – The facility or location where
the Member works most of the time and to which the
Member regularly commutes. If the Member does not
regularly commute to one location, then the Member
does not have a Primary Workplace.
Private-Duty Nursing Services – Private-Duty Nursing
Services encompass nursing services for recipients who
require more individual and continuous care than is
available from a visiting nurse or routinely provided
by the nursing staff of the hospital or Skilled Nursing
Facility.
Provider – A person, group, facility or other entity that
is licensed or otherwise qualified to deliver any of the
Questions? Call the Customer Service Department at 1-800-624-8822. 131
PART A