CALIFORNIA - Pacificare Health Systems

Referral
A formal recommendation by your Primary
Care Physician for you to receive care from a
Specialist or Contracting Medical Provider.
Retiree Benefits Summary and Retiree
Benefits Summary Insert
These documents provide the details of
your particular benefit plan, including any
Copayments and/or Coinsurance that you
should pay when receiving a Covered Service.
Together with this Evidence of Coverage
and Disclosure Information document, the
Retiree Benefits Summary, and the Retiree
Benefits Summary Insert explain your health
care coverage.
Secure Horizons Group Retiree Medicare
Advantage Plan
A Medicare Advantage Plan offered
by PacifiCare, a Medicare Advantage
Organization.
Service Area
A geographic area approved by CMS within
which a Medicare Advantage eligible
individual may enroll in a particular Medicare
Advantage Plan offered by PacifiCare. Service
Areas may contain different benefit plans that
offer different benefits, Health Plan Premiums,
Copayment and Coinsurance amounts.
Skilled Nursing Care
Medically Necessary services that can only be
performed by, or under the supervision of,
licensed nursing personnel.
Skilled Nursing Facility
A facility which provides inpatient Skilled
Nursing Care, rehabilitation services or other
related health services and is state licensed
and/or certified by Medicare. The term
“Skilled Nursing Facility” does not include
a convalescent nursing home, rest facility or
facility for the aged which furnishes primarily
Custodial Care, including training in routines
of daily living.
Section 1 – Health Care Terms
Specialist
Any duly licensed Physician, osteopath,
psychologist or other practitioner (as defined
by Medicare) who provides health care
services for a specific disease, condition
or body part and that your Primary Care
Physician or Contracting Medical Provider
may refer you to. Also any duly licensed
emergency room Physician who provides
Emergency Services to you.
State
The State of California responsible for
licensing and regulating PacifiCare.
Technology Assessment
PacifiCare regularly reviews new procedures,
devices and drugs to determine whether
or not they are safe and efficacious for our
Members. New procedures and technology
that are safe and efficacious are eligible to
become Covered Services. If the technology
becomes a Covered Service it will be subject
to all other terms and conditions of the
plan, including Medical Necessity and any
applicable member copayments, deductibles
or other payment contributions.
In determining whether to cover a service,
PacifiCare uses proprietary technology
guidelines to review new devices, procedures
and drugs, including those related to
behavioral health. When clinical necessity
requires a rapid determination of the
safety and efficacy of a new technology or
new application of an existing technology
for an individual Member, a PacifiCare
Medical Director makes a Medical Necessity
determination based on individual member
medical documentation, review of published
scientific evidence and, when appropriate,
seeks relevant specialty or professional
opinion from an individual who has expertise
in the technology.
Time-Sensitive
A situation in which waiting for a standard
decision on an authorization, request
for services or an Appeal could seriously
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.
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PART B