CALIFORNIA - Pacificare Health Systems

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n n n Emergency Services Urgently Needed Services Out-of-area and routine travel renal dialysis Call Customer Service Whenever You Need Information In addition to arranging health care services, PacifiCare strives to provide the information you need about your Secure Horizons Group Retiree Medicare Advantage Plan when you need it. PacifiCare has specially trained Customer Service Representatives who can answer your questions about: n n n n n n n n n n Covered Services; Making address or telephone number changes; Primary Care Physician selection or changes; Enrollment or Disenrollment; Appeal and Grievance complaint rights; Medical care when you are traveling; The quality of care you are receiving; Information concerning your Physician; Questions about claims; Welcome to the Secure Horizons Group Retiree Medicare Advantage Plan Any other questions or concerns regarding your Secure Horizons Group Retiree Medicare Advantage Plan. Updating Your Membership Records Your Secure Horizons Group Retiree MA Plan membership record contains information from your Election Form, including your address and telephone number, as well as your specific benefit plan coverage, Primary Care Physician and the Contracting Medical Group/IPA you selected upon enrollment. These records are very important because they identify you as an eligible Secure Horizons Group Retiree Medicare Advantage Plan Member and determine where and if you are eligible to receive Covered Services. Please report any changes in name, address or phone number to Customer Service immediately. You should also report any changes in health insurance coverage you have from your employer or your spouse’s employer. Additionally, you should report any liability claims (such as claims against another driver in an auto accident), eligibility under workers’ compensation, and MediCal or Medicaid. PacifiCare Is Interested in Your Comments PacifiCare’s goal is to arrange the Covered Services you need to stay as healthy and active as you can. PacifiCare is interested in your comments. From time to time, PacifiCare will be asking your thoughts on the Secure Horizons Group Retiree Medicare Advantage Plan through voluntary Member satisfaction surveys. These surveys help PacifiCare measure the performance of our Contracting Medical Providers, as well as PacifiCare’s ability to assist you with your health care coverage concerns. How to Submit a Claim All Covered Services prescribed by PacifiCare will be billed to either your Contracting Medical Group/IPA or directly to the plan. However, if you receive a bill for a Covered Service or Emergency Service delivered by a Non-Contracting Medical Provider and receive a bill, please send the claim for determination to: PacifiCare of California Claims Department P.O. Box 489 Cypress, CA 90630 You are responsible for paying any applicable Copayments or Coinsurance amounts directly to the Provider at the time of service. If you have any questions about any claims, please call Customer Service. Questions? Call the Customer Service Department at 1-800-228-2144, (TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m. 143 PART B
PART B Sponsorship and Administration of the Plan The University of California is the Plan sponsor and administrator for the Plan described in this booklet. If you have a question, you may direct it to: 144 Welcome to the Secure Horizons Group Retiree Medicare Advantage Plan University of California Human Resources and Benefits <strong>Health</strong> & Welfare Administration 300 Lakeside Drive, 12th Floor Oakland, CA 94612 1-800-888-8267 Retirees may also direct questions to the University’s Customer Service Center at the above phone number.09
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PacifiCare 5701 Katella Avenue P.O.
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Introducing PacifiCare’s HMO Plan
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Table of Contents Your Billing Prot
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PART A Section 1. Getting Started:
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PART A 6 Getting Started: Your Prim
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PART A Section 2. Seeing the Doctor
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PART A 10 Either you or your treati
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PART A Section 3. Emergency and Urg
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PART A 14 Emergency and Urgently Ne
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PART A 16 Changing Your Doctor or M
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PART A Section 5. Your Medical Bene
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PART A 20 Your Medical Benefits res
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PART A 22 Your Medical Benefits Net
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PART A 24 Your Medical Benefits 10.
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PART A 26 Your Medical Benefits If
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PART A 28 Your Medical Benefits n n
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PART A 30 Your Medical Benefits pro
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PART A 34 Your Medical Benefits X-r
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PART A 36 Your Medical Benefits exp
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PART A 40 Your Medical Benefits n n
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PART A Outpatient Prescription Drug
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PART A n n n 44 Outpatient Prescrip
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PART A 46 Outpatient Prescription D
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PART A Hearing Aid Benefits 48 50 p
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PART A Benefits Available While Hos
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PART A Benefits Available On an Out
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PART A 54 infertility provider(s).
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PART A UNIvERSITY OF CALIFORNIA Beh
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PART A n 58 under your Behavioral H
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PART A 60 How Your Behavioral Healt
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PART A 74 PBHC must provide the fol
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PART A 76 and the results of the re
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PART A Definitions 78 How Your Beha
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PART A 80 Family Member. The Subscr
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PART A Section 7. Payment Responsib
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PART A 86 Payment Responsibility fo
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PART A 88 Payment Responsibility If
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PART A 90 Payment Responsibility in
Page 97 and 98: PART A 92 Member Eligibility Retire
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Page 103 and 104: PART A This section describes how t
Page 105 and 106: PART A n n n 100 The Member no long
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Page 111 and 112: PART A 106 This coverage is subject
Page 113 and 114: PART A Extending Your Coverage: Con
Page 115 and 116: PART A 110 Member Eligibility 4. Yo
Page 117 and 118: PART A 112 Overseeing Your Health C
Page 119 and 120: PART A Quality of Care Review 114 O
Page 121 and 122: PART A Experimental or Investigatio
Page 129 and 130: PART A 124 General Information the
Page 131 and 132: PART A Section 11. Definitions 126
Page 133 and 134: PART A 128 Custodial Care includes
Page 135 and 136: PART A 130 Definitions i. Treating
Page 137 and 138: PART A 132 Definitions health care
Page 139 and 140: PART A Answering Questions 134 Answ
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Page 143 and 144: PART B Please fill this out for you
Page 145 and 146: PART B 140 Table of Contents Religi
Page 147: PART B 142 Welcome to the Secure Ho
Page 151 and 152: PART B 146 Contracting Medical Grou
Page 153 and 154: PART B 148 Section 1 - Health Care
Page 161 and 162: PART B 156 Section 2 - Eligibility,
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Page 169 and 170: PART B Your Secure Horizons Group R
Page 171 and 172: PART B 166 Section 5 - Working With
Page 173 and 174: PART B Section 5 - Working With You
Page 177 and 178: PART B Hospitalist When you are adm
Page 181 and 182: PART B 176 Services for which gover
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Page 187 and 188: PART B 182 As a Member of Secure Ho
Page 189 and 190: PART B 184 Section 8 - Disenrollmen
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Page 197 and 198: PART B 192 decision to process your
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PART B 194 Section 9 - Organization
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PART B n n n 198 Your request to ex
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PART B 200 only means that you rece
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PART B If you have other health ins
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PART B Governing Law This Combined
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PART B You are required to cooperat
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PART B the agreed-upon budget. If t
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PART B You are eligible for enrollm
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PART B THIS NOTICE DESCRIBES HOW ME
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PART B 216 Section 14 - Notice of P
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PART B you in a designated record s
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PART B Addendum to the 2006 Secure
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PART B CALIFORNIA Vision Care Benef
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PART B CALIFORNIA Hearing Aid Benef
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PART B Benefits Available on an Out
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PART B CALIFORNIA Outpatient Prescr
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PART B 230 be appropriate for your
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PART B 232
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CALIFORNIA - Pacificare Health Systems

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