CALIFORNIA - Pacificare Health Systems
CALIFORNIA - Pacificare Health Systems
CALIFORNIA - Pacificare Health Systems
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PART B<br />
140<br />
Table of Contents<br />
Religious Non-Medical <strong>Health</strong> Care 177<br />
Institutions (RNHCIs) Care<br />
Section 6 – Emergency and Urgently 179<br />
Needed Services<br />
What To Do In An Emergency 180<br />
Post-Stabilization Care 180<br />
When You Need Urgent Care and You 180<br />
Are Out of the Area<br />
When You Need Urgent Care and 180<br />
You Are in Your Service Area<br />
Reimbursement for Services 181<br />
Paid by Member<br />
Right to Appeal 181<br />
Section 7 – Premiums and Payment 182<br />
Plan Premiums (“Prepayment Fees”) 182<br />
Changes in <strong>Health</strong> Plan Premiums 182<br />
Other Charges 182<br />
Section 8 – Disenrollment From the 183<br />
Secure Horizons Group Retiree<br />
Medicare Advantage Plan<br />
Voluntary Disenrollment 183<br />
Involuntary Disenrollment 185<br />
Review of Termination and 186<br />
Reinstatement<br />
COBRA Optional Continuation of 186<br />
Coverage Through the University of<br />
California-Sponsored <strong>Health</strong> Plans<br />
California Continuation Coverage 189<br />
Section 9 – Organization 190<br />
Determination, Appeals and<br />
Grievance Procedures<br />
Organization Determinations 190<br />
Expedited/72-Hour Organization 191<br />
Determination Procedures<br />
How Your Expedited/72-Hour 191<br />
Organization Determination Request<br />
Will Be Processed<br />
General Information on the Medicare 192<br />
Appeals Process<br />
Who May File an Appeal 193<br />
Support for Your Appeal 193<br />
Assistance With Appeals 193<br />
Standard Appeal Procedures 193<br />
Expedited/72-Hour Appeal Procedures 196<br />
How to Request an Expedited 196<br />
Reconsideration<br />
How Your Expedited/72-Hour 197<br />
Reconsideration Request Will Be<br />
Processed<br />
Information You Should Receive 198<br />
During Your Hospital Stay<br />
Quality Improvement Review 198<br />
Getting a QIO Review of Your 198<br />
Hospital Discharge<br />
What if you do not ask the QIO for 199<br />
a review by the deadline?<br />
Another Option: Asking for an 199<br />
Expedited/72-Hour Review of Your<br />
Discharge<br />
Termination of Services in Certain 199<br />
Provider Settings (Skilled Nursing Facility<br />
(SNF), Home <strong>Health</strong> Agency (HHA) or<br />
Comprehensive Outpatient Rehabilitation<br />
Facility (CORF))<br />
Review of Termination of SNF, HHA 200<br />
or CORF Services by the QIO<br />
Asking for an Expedited/72-Hour 200<br />
Review of Your Termination of Services<br />
Grievance Procedures 200<br />
Complaints That Do Not Relate to 201<br />
Quality of Medical Care Issues
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