CALIFORNIA - Pacificare Health Systems

If you need urgent medical care within your
Service Area:
1. Call your Contracting Medical Group/IPA
at the number listed on your membership
card.
2. Identify yourself as a Secure Horizons
Group Retiree Medicare Advantage Plan
Member and let them know you feel you
need immediate medical attention.
3. Follow any first-aid instructions provided
(you may be advised to go to your
Provider or to a nearby Hospital).
All Contracting Medical Groups/IPAs have
a 24-hour emergency number. If, for any
reason, you are unable to reach your
Contracting Medical Provider, follow the steps
for out-of-area Urgently Needed Services
as previously described. Follow-up medical
care must be received or authorized by your
Primary Care Physician or Contracting Medical
Group/IPA.
Reimbursement for Services Paid by
Member
Providers should submit bills to PacifiCare
for payment. However, if you paid for any
Emergency Services or Urgently Needed
Services or emergency out-of-area and
routine travel dialysis obtained from Non-
Contracting Medical Providers, you should
submit your bills to PacifiCare for a payment
determination. Bills should be submitted to
the following address:
PacifiCare Claims Department
P.O. Box 489
Cypress, CA 90630
If you have questions about any bills, contact
Customer Service.
Right to Appeal
PacifiCare provides you with a written notice if
a service or payment is denied. If PacifiCare has
denied payment for services you think should
have been covered, or if PacifiCare refused to
arrange for services that you believe are covered
by Medicare, you have the right to appeal. If you
Section 6 – Emergency and
Urgently Needed Services
think waiting for a decision about authorization
for a service could seriously harm your health,
you may request an Expedited Appeal. (Please see
Section 9.)
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.
181
PART B