CALIFORNIA - Pacificare Health Systems

for Emergency or Urgently Needed
Services.
Hospitalization
If your Primary Care Physician or Specialist
determines you require Hospitalization,
Outpatient Services, Home Health Care or
Skilled Nursing Care, he or she will arrange
these Covered Services for you.
Coverage for Acute Care (referred to in the
Member materials as “inpatient Hospital
benefits”) consists of Medically Necessary
inpatient Hospital services authorized by your
Contracting Medical Group/IPA or PacifiCare,
including Hospital room, intensive care,
definitive observation, isolation, operating
room, recovery room, labor and delivery
room, laboratory, diagnostic and therapeutic
radiology, nuclear medicine, pharmacy,
inhalation therapy, dialysis, EKG, EEG, EMG,
blood and blood plasma, anesthesia supplies,
surgically implanted devices and implanted
breast prosthesis post-mastectomy, nursing
services, professional charges by the Hospital
pathologist or radiologist, coordinated
discharge planning and other miscellaneous
Hospital charges for Medically Necessary care
and treatment.
Coverage for Acute Care and subacute care
includes Medically Necessary inpatient
services authorized by your Contracting
Medical Provider provided in an Acute Care
Hospital, a comprehensive, free-standing
acute rehabilitation facility, or a specially
designed unit within a Skilled Nursing Facility.
With the exception of Emergency or Urgently
Needed Services, you will only be admitted
to those Hospitals, Acute Care, subacute care,
transitional inpatient care and Skilled Nursing
Facilities that are Prior Authorized by your
Contracting Medical Group/IPA and under
contract with PacifiCare.
You may call Customer Service to request a
copy of PacifiCare’s Utilization Review and
Prior Authorization processes that apply to
care provided in subacute care, transitional
inpatient care and Skilled Nursing Facilities.
Section 5 – Working With Your
Contracting Medical Providers
PacifiCare’s Medical Director or designee
determines the Hospital or Outpatient
Services facility designated by PacifiCare for
elective services. PacifiCare reserves the right
to transfer patients who are stable for transfer
to other facilities based upon factors which
may include Contracting Medical Provider
Hospital privileges, capabilities of the
Hospital, and outcomes.
Please note: PacifiCare will not pay federal
Hospitals, such as Veterans’ Administration
(VA) Hospital, for emergency and nonemergency
items and services furnished
to veterans, retired military personnel or
eligible dependents. However, PacifiCare will
reimburse Members who are Veterans, retired
military personnel or eligible dependents for
any Copayments or Coinsurance paid to the
VA Hospitals for Emergency Services, up to
the amount of the Secure Horizons Group
Retiree Medicare Advantage Plan Emergency
Services Copayment. For Members who are
not eligible for VA benefits, PacifiCare will
cover emergency, urgent and post-stabilization
care provided by a VA facility; these services
are considered out-of-network.
Hospital Copayments and Benefit
Periods
Inpatient Hospital care Copayments are
charged for each Hospital Stay. Once you are
discharged from a Hospital, any subsequent
Hospital admissions, even for the same
medical condition at the same Hospital, will
require a Hospital Copayment. In certain
circumstances, you may be discharged from a
Hospital and transferred to a Skilled Nursing
Care unit or transitional care unit within the
same Hospital. If you are later readmitted to
the Hospital from the Skilled Nursing Care
unit or transitional care unit, you will pay
the Hospital Copayment. Original Medicare
Hospital benefit periods do not apply. For
inpatient Hospital care, you are covered
for an unlimited number of days as long
as the Hospital Stay is Medically Necessary
and authorized by PacifiCare or contracting
providers.
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