CALIFORNIA - Pacificare Health Systems

Standing Referrals to Specialists
A standing referral is a referral by your Primary Care
Physician that authorizes more than one visit to a
participating specialist. A standing referral may be
provided if your Primary Care Physician, in consultation
with you, the specialist and your Participating Medical
Group’s Medical Director (or a PacifiCare Medical
Director), determines that as part of a treatment plan
you need continuing care from a specialist. You may
request a standing referral from your Primary Care
Physician or PacifiCare. PLEASE NOTE: A standing
referral and treatment plan is only allowed if approved
by your Participating Medical Group or PacifiCare. Your
Primary Care Physician will specify how many specialist
visits are authorized. The treatment plan may limit
your number of visits to the specialist and the period
for which visits are authorized. It may also require the
specialist to provide your Primary Care Physician with
regular reports on your treatment and condition.
Extended Referral for Care by a Specialist
If you have a life-threatening, degenerative or disabling
condition or disease that requires specialized medical
care over a prolonged period, you may receive an
“extended specialty referral.” This is a referral to a
participating specialist or specialty care center, so the
specialist can oversee your health care. The Physician
or center will have the necessary experience and skills
for treating the condition or disease.
You may request an extended specialty referral by
asking your Primary Care Physician or PacifiCare. Your
Primary Care Physician must then determine if it is
Medically Necessary. Your Primary Care Physician will
do this in consultation with the specialist or specialty
care center, as well as your Participating Medical
Group’s Medical Director or a PacifiCare Medical
Director.
If you require an extended specialty referral, the
referral will be made according to a treatment plan
approved by your Participating Medical Group’s
Medical Director or a PacifiCare Medical Director.
This is done in consultation with your Primary Care
Physician, the specialist and you. Once the extended
specialty referral begins, the specialist begins serving as
the main coordinator of your care. The specialist does
this in accordance with your treatment plan.
OB/GYN: Getting Care Without a Referral
Women may receive obstetrical and gynecological (OB/
GYN) Physician services directly from a Participating
OB/GYN, family practice Physician, or surgeon
identified by your Participating Medical Group as
providing OB/GYN Physician services. This means you
may receive these services without Preauthorization
or a referral from your Primary Care Physician. In all
cases, however, the doctor must be affiliated with your
Participating Medical Group.
PLEASE REMEMBER: If you visit an OB/GYN or family
practice Physician not affiliated with your Participating
Medical Group without Preauthorization or a referral,
you will be financially responsible for these services.
All OB/GYN inpatient or Hospital Services, except
Emergency or Urgently Needed Services, need to be
authorized in advance by your Participating Medical
Group or PacifiCare.
If you would like to receive OB/GYN Physician services,
simply do the following:
n
n
Seeing the Doctor
Call the telephone number on the front of your
ID card and request the names and telephone
numbers of the OB/GYNs affiliated with your
Participating Medical Group;
Telephone and schedule an appointment with your
selected Participating OB/GYN.
After your appointment, your OB/GYN will contact
your Primary Care Physician about your condition,
treatment and any needed follow-up care.
PacifiCare also covers important wellness services
for our Members. For more information, see “Health
Education Services” in Section 5: Your Medical
Benefits.
Second Medical Opinions
A second medical opinion is a reevaluation of your
condition or health care treatment by an appropriately
qualified Provider. This Provider must be either a
Primary Care Physician or a specialist acting within his
or her scope of practice and must possess the clinical
background necessary for examining the illness or
condition associated with the request for a second
medical opinion. Upon completing the examination,
the Provider’s opinion is included in a consultation
report.
Questions? Call the Customer Service Department at 1-800-624-8822. 9
PART A