CALIFORNIA - Pacificare Health Systems

circumstances, to transfer you to a Participating
Hospital in lieu of authorizing post-stabilization
services at the treating facility.
Following your discharge from the Hospital, any
Medically Necessary follow-up medical or Hospital
Services must be provided or authorized by your
Primary Care Physician in order to be covered
by PacifiCare. Regardless of where you are in the
world, if you require additional follow-up medical
or Hospital Services, please call your Primary Care
Physician or PacifiCare’s out-of-area unit to request
authorization. PacifiCare’s out-of-area unit can be
reached during regular business hours (8 a.m. –
5 p.m. PST) at 1-800-762-8456.
Out-of-Area Services
PacifiCare arranges for the provision of Covered
Services through its Participating Medical Groups
and other Participating Providers. With the exception
of Emergency Services, Urgently Needed Services,
authorized post-stabilization care or other specific
services authorized by your Participating Medical
Group or PacifiCare, when you are away from the
geographic area served by your Participating Medical
Group, you are not covered for any other medical or
Hospital Services. If you do not know the area served
by your Participating Medical Group, please call your
Primary Care Physician or the Participating Medical
Group’s administrative office to inquire.
The out-of-area services that are not covered include,
but are not limited to:
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Routine follow-up care to Emergency or Urgently
Needed Services, such as treatments, procedures,
X-rays, lab work and doctor visits, Rehabilitation
Services, Skilled Nursing Care or home health care.
Maintenance therapy and durable medical
equipment, including, but not limited to, routine
dialysis, routine oxygen, routine laboratory testing
or a wheelchair to assist you while traveling outside
the geographic area served by your Participating
Medical Group.
Medical care for a known or Chronic Condition
without acute symptoms as defined under
Emergency Services or Urgently Needed Services
Emergency and
Urgently Needed Services
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Ambulance services are limited to transportation to
the nearest facility with the expertise for treating
your condition.
Your Participating Medical Group provides 24-hour
access to request authorization for out-of-area care. You
can also request authorization by calling the PacifiCare
out-of-area Unit during regular business hours (8 a.m.
– 5 p.m. PST) at 1-800-762-8456.
What To Do When You Require Urgently
Needed Services
If you need Urgently Needed Services when you are
in the geographic area served by your Participating
Medical Group, you should contact your Primary
Care Physician or Participating Medical Group. The
telephone numbers for your Primary Care Physician
and/or Participating Medical Group are on the front
of your PacifiCare ID card. Assistance is available 24
hours a day, seven days a week. Identify yourself as
a PacifiCare Member and ask to speak to a Physician.
If you are calling during nonbusiness hours and a
Physician is not immediately available, ask to have the
Physician-on-call paged. A Physician should call you
back shortly. Explain your situation and follow any
provided instructions. If your Primary Care Physician or
Participating Medical Group is temporarily unavailable
or inaccessible, you should seek Urgently Needed
Services from a licensed medical professional wherever
you are located.
You, or someone else on your behalf, must notify
PacifiCare or your Participating Medical Group within
24 hours, or as soon as reasonably possible, after the
initial receipt of Urgently Needed Services. When you
call, please be prepared to give a description of the
Urgently Needed Services that you received.
Out-of-Area Urgently Needed Services
Urgently Needed Services are Medically Necessary
health care services required to prevent the serious
deterioration of a Member’s health, resulting from an
unforeseen illness or injury for which treatment cannot
be delayed until the Member returns to the geographic
area served by the Member’s Participating Medical
Group.
Urgently Needed Services are required in situations
where a Member is temporarily outside the geographic
area served by the Member’s Participating Medical
Group and the Member experiences a medical
Questions? Call the Customer Service Department at 1-800-624-8822. 13
PART A