CALIFORNIA - Pacificare Health Systems

PART B
Section 9 – Organization Determination,
Appeals and Grievance Procedures
of your right to a standard and expedited
reconsideration (Appeal) process and the right
to appoint a representative to file an Appeal on
your behalf. You also have the right to submit
additional information regarding the requested
service in writing or in person. If you have not
received such a notice within fourteen (14)
calendar days of your request for services, or
within sixty (60) calendar days of a request for
payment, you may assume the decision is a
denial, and you may file an Appeal.
Expedited/72-Hour Organization
Determination Procedures
You have the right to request and receive
expedited decisions affecting your medical
treatment in “Time-Sensitive” situations. A
Time-Sensitive situation is a situation where
waiting for a decision to be made within the
time frame of the standard decision-making
process could seriously jeopardize your life
or health, or your ability to regain maximum
function. If PacifiCare, your Primary Care
Physician or Contracting Medical Group/IPA
decides, based on medical criteria, that your
situation is Time-Sensitive or if any physician
calls or writes in support of your request for
an expedited review, PacifiCare, your Primary
Care Physician or Contracting Medical Group/
IPA will issue a decision as expeditiously as
possible, but no later than seventy-two (72)
hours after receiving the request. PacifiCare,
your Primary Care Physician or Contracting
Medical Group/IPA may extend this time frame
by up to fourteen (14) calendar days if you
request the extension or if PacifiCare, your
Primary Care Physician or Contracting Medical
Group/IPA needs additional information,
and the extension of time benefits you (for
example, if PacifiCare, your Primary Care
Physician or Contracting Medical Group/IPA
needs additional medical records from Non-
Contracted Medical Providers that could
change a denial decision). If the time frame is
extended, you will be notified of the reasons
for the delay and informed of your right to
file a Grievance should you disagree with an
extension. You will be notified promptly of the
organization determination, but no later than
upon expiration of the extension.
If you believe you need a service and you
believe it is a Time-Sensitive situation, you or
any physician, including a physician with no
connection to PacifiCare, may request that
the decision be expedited. If PacifiCare, your
Primary Care Physician or Contracting Medical
Group/IPA decides that it is a Time-Sensitive
situation or if any physician indicates that
applying the standard time frame for making
a determination could seriously jeopardize
your life or health or your ability to regain
maximum function, PacifiCare, your Primary
Care Physician or Contracting Medical Group/
IPA will make a decision on your request for a
service on an expedited/72-hour basis (subject
to extension as discussed below).
To request an expedited seventy-two (72)-hour
Organization Determination call PacifiCare or
your Primary Care Physician. Be sure to ask
for an expedited seventy-two (72)-hour
review when you make your request.
How Your Expedited/72-Hour
Organization Determination Request
Will Be Processed
1. Upon receiving your request, PacifiCare,
your Primary Care Physician or Contracting
Medical Group/IPA will determine if your
request meets the definition of Time-
Sensitive.
If your request does not meet the
definition, it will be handled within the
standard review time frames (fourteen
(14) calendar days for organization
determinations). You will be informed
by telephone that your request for
the expedited seventy-two (72)-hour
review has been denied and will also
receive a written confirmation that
the request will be processed within
the standard review time frame,
within three (3) calendar days of the
telephone call. If you disagree with
PacifiCare, your Primary Care Physician’s
or Contracting Medical Group’s/IPA’s
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