CALIFORNIA - Pacificare Health Systems
CALIFORNIA - Pacificare Health Systems
CALIFORNIA - Pacificare Health Systems
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Complaints Involving Quality of 201<br />
Medical Care Issues<br />
QIO Quality of Care Complaint Process 201<br />
Binding Arbitration 202<br />
Section 10 – Advance Directives: 203<br />
Making Your <strong>Health</strong> Care Wishes<br />
Known<br />
Section 11 – Coordinating Other 204<br />
Benefits You May Have<br />
Who pays first? 204<br />
Section 12 – General Provisions 206<br />
Governing Law 206<br />
Your Financial Liability as a Secure 206<br />
Horizons Group Retiree Medicare<br />
Advantage Plan Member<br />
Secure Horizons Group Retiree 206<br />
Medicare Advantage Plan Member<br />
Member Non-Liability 206<br />
Third-Party Liability 207<br />
Acts Beyond the Control of PacifiCare 208<br />
Contracting Medical Providers Are 208<br />
Independent Contractors<br />
PacifiCare’s Contracting<br />
Arrangements<br />
208<br />
Physician-Patient Relationship 208<br />
Facility Locations 208<br />
Notices 209<br />
Technology Assessment 209<br />
Practitioners and Utilization Review 209<br />
How PacifiCare’s Contracting<br />
Providers Are Compensated<br />
209<br />
Public Policy Participation 210<br />
Important Information About 210<br />
Organ and Tissue Donations<br />
Table of Contents<br />
Section 13 – Secure Horizons Group 212<br />
Retiree MA Plan Service Area<br />
Section 14 – Notice of Privacy 214<br />
Practices<br />
Our Privacy Practices 214<br />
<strong>Health</strong> Care Information Maintained 214<br />
at PacifiCare<br />
How We May Use or Share 215<br />
Your Information<br />
Questions Regarding Use and 219<br />
Disclosure and Your Privacy Rights<br />
PacifiCare’s Family of Companies 219<br />
Section 15 – Addendum 220<br />
Addendum to the 2006 Secure 220<br />
Horizons Group Retiree Medicare<br />
Advantage Evidence of Coverage and<br />
Disclosure Information<br />
ERISA Requirements 220<br />
Qualified Medical Child Support Order 220<br />
Your Provider Directory – Choice of 220<br />
Physicians and Hospital (Facilities)<br />
Notifying You of Changes in Your 220<br />
Secure Horizons Group Retiree<br />
Medicare Advantage Plan<br />
Newborn’s and Mother’s Rights Act 221<br />
Women’s <strong>Health</strong> and Cancer 221<br />
Rights Act<br />
Vision Care Benefit 222<br />
Hearing Aid Benefits 224<br />
Medical Schedule of Benefits 225<br />
Outpatient Prescription Drug 228<br />
Program Schedule of Benefits<br />
Behavioral <strong>Health</strong> Schedule of 229<br />
Benefits<br />
Questions? Call the Customer Service Department at 1-800-228-2144,<br />
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.<br />
141<br />
PART B
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