CALIFORNIA - Pacificare Health Systems

you in selecting a new Primary Care Physician
or arranging access to all Covered Services.
How to Schedule an Appointment With
Your Primary Care Physician
To schedule an appointment, call your
Primary Care Physician’s office. There are
no special rules to follow. Appointments are
scheduled according to the type of medical
care you are requesting. Medical conditions
requiring more immediate attention are
scheduled sooner. If you have difficulty
obtaining an appointment with your Primary
Care Physician, please call Customer Service.
The telephone number for your Primary Care
Physician and/or Contracting Medical Group/
IPA is listed on your Secure Horizons Group
Retiree MA Plan membership card.
If at all possible, please call your Primary
Care Physician 24 hours in advance if you are
unable to keep a scheduled appointment.
How to Receive Care After-Hours
If you need to talk to or see your Primary
Care Physician after the office has closed for
the day, call your Primary Care Physician’s
office. When the Physician on-call returns
your call, he or she will advise you on how
to proceed. See Section 6 Emergency and
Urgently Needed Services for what to do in
cases of an emergency.
How to Receive Covered Services From
a Specialist
Even though your Primary Care Physician is
trained to handle the majority of common
health care needs, there may be a time when
he or she feels you need more specialized
treatment. In that case, you may receive a
Referral to an appropriate Specialist. In some
cases, the request for a Referral will need
to have Prior Authorization from PacifiCare
or your Contracting Medical Group/IPA.
When you select a Primary Care Physician,
it is important to remember that this limits
you to the Network of Specialists who are
affiliated with your Primary Care Physician’s
Contracting Medical Group/IPA.
Section 5 – Working With Your
Contracting Medical Providers
Neither PacifiCare nor Medicare will pay
for your care if you receive services from
a Specialist without a Referral from your
Primary Care Physician or Contracting
Medical Group/IPA or Prior Authorization
from PacifiCare, except for Emergency or
Urgently Needed Services.
Occasionally, Specialists contracting with
PacifiCare are involuntarily terminated.
PacifiCare or your Contracting Medical Group/
IPA will make a good faith effort to inform
you of your right to maintain your treatment
with the Specialist through other avenues,
which may include joining a different
Medicare Advantage Coordinated Care Plan or
returning to Medicare.
Please refer to the Provider Directory for a
listing of Specialists available to you through
your selected Contracting Medical Group/
IPA. For a copy of the most recent Provider
Directory, or to seek additional assistance,
please call Customer Service or you may
consult the online Provider Directory at
www.securehorizons.com.
Standing Referrals to Specialists
You may receive a standing Referral to a
Specialist if your Primary Care Physician
determines, in consultation with the Specialist
and your Contracting Medical Group/IPA’s
Medical Director or a PacifiCare Medical
Director, that you need continuing care from
a Specialist. A “standing Referral” means
a Referral by your Primary Care Physician
for more than one visit to a Specialist as
indicated in the treatment plan without the
Primary Care Physician having to provide a
specific Referral for each visit. The standing
Referral will be made according to a
treatment plan approved by your Contracting
Medical Group/IPA or PacifiCare Medical
Director, in consultation with your Primary
Care Physician, the Specialist, and you, if you
have a complex or serious medical condition
or a treatment plan is otherwise considered
necessary. The treatment plan may limit the
number of visits to the Specialist or may limit
the period of time the visits are authorized.
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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