CALIFORNIA - Pacificare Health Systems

PART B
146
Contracting Medical Group/Independent
Physicians Association (IPA)
Contracting Medical Groups are Physicians
organized as a legal entity for the purpose
of providing medical care. The Contracting
Medical Group has an agreement with
PacifiCare to provide medical services
to Members. Independent Physicians
Associations (IPAs) are organizations or
affiliated groups of Physicians that deliver
or arrange for the delivery of health services
and function as Contracting Medical Groups
with Physicians practicing out of their own
independent medical offices.
Contracting Medical Provider
A health professional, a supplier of health
items, or a health care facility having an
agreement with PacifiCare or a Contracting
Medical Group/IPA to provide or coordinate
medical services to Members. Contracting
Medical Providers are independent
contractors and are not the employees or
agents of PacifiCare.
Coordinated Care Plans
These are Medicare Advantage Plans that
use a network of Providers which are under
contract or arrangement with a Medicare
Advantage Organization or its Contracting
Medical Groups/IPAs to provide covered
benefits. The Secure Horizons Medicare
Advantage Plan is a Coordinated Care Plan.
Copayment
The fee you pay at the time of medical
services in accordance with your Secure
Horizons Group Retiree MA Plan.
Covered Services
Those benefits, services and supplies listed
in the Retiree Benefits Summary and Retiree
Benefits Summary Insert which are:
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Section 1 – Health Care Terms
Services provided or furnished by
Contracting Medical Providers or
authorized by PacifiCare or Contracting
Medical Providers.
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Emergency Services and Urgently Needed
Services for which you do not need Prior
Authorization and which may be provided
by Non-Contracting Providers. (Please
refer to Section 6 for more information
about Emergency Services and Urgently
Needed Services.)
Post-stabilization services furnished by
Non-Contracting Providers or Facilities
that are Prior Authorized by PacifiCare
or were not Prior Authorized because
PacifiCare did not respond to a request
for Prior Authorization for such services
within one (1) hour of the request or
because PacifiCare could not be contacted
for Prior Authorization.
Renal Dialysis services provided while you
are temporarily outside the Service Area.
Any services for which PacifiCare provides
Prior Authorization.
Custodial Care
Not a Covered Service. Custodial Care
includes services that assist an individual
in the activities of daily living. Examples
include: assistance in walking, getting in
or out of bed, bathing, dressing, feeding
and using the toilet; preparation of special
diets; and supervision of the administration
of medication that usually can be selfadministered.
Custodial Care includes
all homemaker services, respite care,
convalescent care or extended care not
requiring skilled nursing. Custodial Care
does not require the continuing attention of
trained medical or paramedical personnel.
Customer Service
A department dedicated to answering your
questions concerning (but not limited
to) your membership, Covered Services,
Grievances and Appeals.
Disenroll or Disenrollment
The process of ending your membership
in the Secure Horizons Group Retiree
Medicare Advantage Plan. Disenrollment can