CALIFORNIA - Pacificare Health Systems

PART B
180
IPA or PacifiCare within forty-eight (48) hours
or as soon as reasonably possible after the
emergency so he or she can arrange for your
follow-up care.
Post-Stabilization Care
Medically Necessary, non-Emergency Services
following receipt of emergency care to
enable you to remain stabilized are covered:
when PacifiCare or its Contracting Medical
Providers do not respond within one (1)
hour to a request for a Prior Authorization
from a Non-Contracting Provider or Facility;
or when PacifiCare or its Contracting Medical
Providers could not be contacted for Prior
Authorization.
Coverage for post-stabilization care provided
by a Non-Contracting Provider continues to
be covered until one of the following:
n
n
n
n
You are discharged
A Contracting Medical Provider arrives and
assumes responsibility for your care
The Non-Contracting Provider and
PacifiCare agree to other arrangements
A Contracting Medical Provider assumes
responsibility for your care through the
transfer to a contracting facility
When You Need Urgent Care and You
Are Out of the Area
The Secure Horizons Group Retiree Medicare
Advantage Plan also covers Urgently Needed
Services. Urgently Needed Services are
Covered Services provided when you
are temporarily* absent from the area
served by your Primary Care Physician
or Contracting Medical Group/IPA
(or, under unusual and extraordinary
circumstances, you are in the Service Area
but your Contracting Medical Group/IPA
is temporarily unavailable or inaccessible)
when such services are Medically
Necessary and immediately required:
n
Section 6 – Emergency and
Urgently Needed Services
as a result of an unforeseen illness,
injury, or condition, and
n
it is not reasonable given the
circumstances to obtain the services
through your Primary Care Physician.
*A temporary absence is an absence from the
Service Area lasting not more than six months
and it is not a permanent move.
If such a medical need arises, PacifiCare
requests that, if possible, you first contact
your Primary Care Physician or PacifiCare,
then seek care from a local doctor. If this
is not possible, you may seek care from a
Hospital emergency room or other medical
facility.
If you must visit a Provider or a Hospital
emergency room for Urgently Needed
Services when outside the Service Area, you
should contact your Primary Care Physician or
Contracting Medical Group/IPA or PacifiCare
within forty-eight (48) hours or as soon as
reasonably possible, so that PacifiCare can
be involved in the management of your care.
After treatment for out of the Service Area
Urgently Needed Care, follow-up care that
does not continue to meet the definition
of Urgently Needed Care must be received
in the Service Area from your Primary Care
Physician. If you receive out of the Service
Area follow-up care that does not meet the
definition of Urgently Needed Care, you may
be financially responsible for the cost of the
follow-up care.
If you receive services without Prior
Authorization, except for Emergency
Services, Urgently Needed Services, outof-area
and routine travel renal dialysis,
neither PacifiCare nor Medicare will pay
for those services.
When You Need Urgent Care and You
Are in Your Service Area
Many Contracting Medical Providers have onsite
urgent care centers. Many of these centers
have extended hours and do not require
appointments. PacifiCare encourages you
to take advantage of this convenience in an
urgent medical situation.