CALIFORNIA - Pacificare Health Systems

PART B
154
Section 1 – Health Care Terms
jeopardize your life, health, or your ability to
recover from an illness, injury or condition.
Urgently Needed Services
Covered Services provided when you
are temporarily absent from the Secure
Horizons Group Retiree Medicare Advantage
Plan Service Area (or, under unusual and
extraordinary circumstances, provided when
you are in the Service Area, but your Primary
Care Physician is temporarily unavailable or
inaccessible) when such services are Medically
Necessary and immediately required: (1) as
a result of an unforeseen illness, injury, or
condition; and (2) it is not reasonable given
the circumstances to obtain the services
through your Primary Care Physician.
Utilization Review
A comprehensive, integrated process in which
a team of health care professionals evaluates
your treatment in an effort to promote the
efficient use of resources and the quality
of health care. Duties of the Utilization
Review staff include prior authorization,
concurrent and retrospective review of
medical services. Prior Authorization is the
process of obtaining prior approval as to the
coverage and appropriateness of service, as
defined in Section 1 (Health Care Terms) and
described in Section 4 (How Your Secure
Horizons Medicare Advantage Plan Coverage
Works). Concurrent and retrospective review
is an assessment, which determines Medical
Necessity or appropriateness of services as
they are being or have already been rendered,
as applicable.