CALIFORNIA - Pacificare Health Systems

PART A
14
Emergency and
Urgently Needed Services
condition that, while less serious than an Emergency
Medical Condition, could result in the serious
deterioration of the Member’s health if not treated
before the Member returns to the geographic area
served by his or her Participating Medical Group or
contacts his or her Participating Medical Group.
When you are temporarily outside the geographic area
served by your Participating Medical Group and you
believe that you require Urgently Needed Services,
you should, if possible, call (or have someone else
call on your behalf) your Primary Care Physician or
Participating Medical Group as described in “What To
Do When You Require Urgently Needed Services.” 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 you are unable to contact your Primary Care
Physician or Participating Medical Group, 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.
International Emergency and Urgently Needed
Services
If you are out of the country and require Urgently
Needed Services, you should still, if possible, call your
Primary Care Physician or Participating Medical Group.
Just follow the same instructions outlined above. If you
are out of the country and experience an Emergency
Medical Condition, either use the available emergency
response system or go directly to the nearest Hospital
emergency room. Following receipt of Emergency
Services, please notify your Primary Care Physician or
Participating Medical Group within 24 hours, or as
soon as reasonably possible, after initially receiving
these services.
Note: Under certain circumstances, you may need to
initially pay for your Emergency or Urgently Needed
Services. If this is necessary, please pay for such
services and then contact PacifiCare at the earliest
opportunity. Be sure to keep all receipts and copies of
relevant medical documentation. You will need these
to be properly reimbursed. For more information on
submitting claims to PacifiCare, please refer to Section
7. Payment Responsibility in this Combined Evidence
of Coverage and Disclosure Form.
Always Remember
Emergency Services: Following receipt of Emergency
Services, you, or someone else on your behalf, must
notify PacifiCare or your Primary Care Physician within
24 hours, or as soon as reasonably possible, after
initially receiving these services.
Urgently Needed Services: When you require
Urgently Needed Services, you should, if possible,
call (or have someone else call on your behalf) your
Primary Care Physician or Participating Medical
Group. If you are unable to contact your Primary Care
Physician or Participating Medical Group, and you
receive medical or Hospital Services, you must notify
PacifiCare or your Primary Care Physician within 24
hours, or as soon as reasonably possible, of initially
receiving these services.