CALIFORNIA - Pacificare Health Systems

PART B
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decision to process your request
within the standard time frame, you
may file an expedited Grievance with
PacifiCare. The written confirmation
letter will include instructions on how
to file a Grievance. If your request is
Time-Sensitive, you will be notified
of PacifiCare’s, your Primary Care
Physician’s or Contracting Medical
Group’s/IPA’s decision within seventytwo
(72) hours. You will also receive
a follow-up letter within three (3)
calendar days of the phone call.
2. Your request must be processed within
seventy-two (72) hours if any physician
calls or writes in support of your request
for an expedited seventy-two (72)-hour
review, and the physician indicates that
applying the standard review time frame
could seriously jeopardize your life or
health or your ability to regain maximum
function.
If a Non-Contracted Medical Provider
supports your request, PacifiCare, your
Primary Care Physician or Contracting
Medical Group/IPA will have seventy-two
(72) hours from the time all the necessary
medical information is received from that
Provider to make a decision.
3. PacifiCare, your Primary Care Physician
or Contracting Medical Group/IPA will
make a decision and notify you of it within
seventy-two (72) hours of receipt of your
request. If PacifiCare your Primary Care
Physician or Contracting Medical Group/
IPA do not approve your request, you can
Appeal to PacifiCare (see below):
There are four possible dispositions to
a request for an expedited organization
determination:
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Section 9 – Organization Determination,
Appeals and Grievance Procedures
Your request to expedite an organization
determination decision is accepted;
PacifiCare, your Primary Care Physician
or Contracting Medical Group/IPA makes
a decision in seventy-two (72) hours and
notifies you that they will arrange or
continue the service.
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Your request to expedite an organization
determination decision is accepted;
PacifiCare, your Primary Care Physician
or Contracting Medical Group/IPA makes
a decision in seventy-two (72) hours and
notifies you that they will not arrange or
continue the service, and you can Appeal
to PacifiCare.
Your request to expedite the organization
determination is not accepted, and
PacifiCare, your Primary Care Physician
or Contracting Medical Group/IPA
informs you that your request will be
handled under the standard organization
determination process.
Your request to expedite an organization
determination cannot be made in seventytwo
(72) hours, and PacifiCare, your
Primary Care Physician or Contracting
Medical Group/IPA informs you that they
will need up to an additional fourteen
(14) calendar days to process your
request.
If you have questions regarding these rights,
please call Customer Service.
General Information on the Medicare
Appeals Process
As a Secure Horizons Group Retiree Medicare
Advantage Plan Member, you have the right to
appeal any organization determination about
PacifiCare’s payment for, or failure to arrange
or continue to arrange for, what you believe
are Covered Services under your Medicare
Advantage Plan. These include the following:
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Payment for out-of-area renal dialysis and
routine travel dialysis services, Emergency
Services, Post-Stabilization Care, or
Urgently Needed Services
Payment for any other health services
furnished by a Non-Contracted Medical
Provider or Facility you believe are covered
under Original Medicare or should have
been arranged for, or reimbursed by
PacifiCare
Services you have not received, but you
believe are the responsibility of PacifiCare
to pay for or arrange
PART B