CALIFORNIA - Pacificare Health Systems

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an acute condition (such as open surgical
wounds, or recent heart attack);
serious chronic condition (such as
chemotherapy or radiation therapy);
a high-risk pregnancy (such as multiple
babies where there is a high likelihood of
complications);
pregnancy in the second or third
trimester;
and your Physician is terminated, you may
request to continue receiving treatment
from the terminated Physician beyond the
termination date by calling Customer Service.
Your Contracting Medical Group/IPA’s Medical
Director in consultation with your terminated
Physician will determine the best way to
manage your ongoing care. PacifiCare must
provide Prior Authorization of services for
continued care. If you have any questions, or
would like a copy of PacifiCare’s Continuity of
Care Policy, or would like to Appeal a denial
of your request for continuation of services
from your terminated Physician, you may call
Customer Service.
If PacifiCare terminates the contract with
your Primary Care Physician, Specialist or
Contracting Medical Group/IPA, you may be
eligible for enrollment in a Secure Horizons
Medicare Supplement policy on a guaranteed
issue basis. For more information or to enroll,
please contact PacifiCare at 1-800-610-2660
or (TDHI) 1-800-387-1074, 6:00 a.m. to 6:00
p.m., Monday through Friday.
Access to Your Medical Records and
Files
You have the right to access your medical
records and files. PacifiCare must provide
timely access to your records and any
information that pertains to them. Please
contact your contracting Medical Provider
directly for a copy of your medical records.
Except as authorized by Federal and
state laws, PacifiCare must obtain written
permission from you or your authorized
representative before medical records can
be made available to any person not directly
Section 5 – Working With Your
Contracting Medical Providers
concerned with your care or responsible for
making payments for the cost of such care.
Utilization Review
PacifiCare and its Contracting Medical
Groups/IPAs use processes to review,
approve, modify, delay, or deny, based on
Medical Necessity, requests by Providers
for authorization of the provision of health
care services to Members. This process of
Utilization Review (or medical management)
is a way to make sure that Members receive
the right care, at the right place, by the right
Provider.
PacifiCare and its Contracting Medical
Groups/IPAs may also use Utilization Review
criteria or guidelines to determine whether
to approve, modify, delay, or deny, based
on Medical Necessity, requests by Providers
of health care services for Members. The
criteria used as the basis of a decision to
modify, delay, or deny requested health care
services in a specific case under review will
be disclosed to the Provider and the Member
in that specific case. The criteria or guidelines
used to determine whether to authorize,
modify, delay, or deny health care services are
available to the public upon request, limited
to the criteria or guidelines for the specific
procedure or condition requested.
Decisions to modify, delay, or deny requests
for authorization of health care services for
a Member, based on Medical Necessity, are
made only by licensed Physicians.
PacifiCare and its Contracting Medical
Groups/IPA make these decisions within at
least the time frames required by federal law
or regulation. Please see Section 9 of this
Evidence of Coverage for specific information
regarding the time frames by which PacifiCare
must make a determination (decision) on
your request for payment or the provision of
health care services.
If you have general questions regarding
Utilization Review and/or would like a copy
of PacifiCare’s policies and procedures (a
description of the processes utilized for
authorization, modification, delay, or denial
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