CALIFORNIA - Pacificare Health Systems

Section 4. Changing Your Doctor or Medical
Group
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How To Change Your Primary Care Physician
How To Change Your Participating Medical
Group
When We Change Your Physician or Medical
Group
When Medical Groups or Doctors Are Terminated
by PacifiCare
There may come a time when you want or need to
change your Primary Care Physician or Participating
Medical Group. This section explains how to make this
change, as well as how we continue your care.
Changing Your Primary Care Physician
Whether you want to change doctors within your
Participating Medical Group or transfer out of your
Participating Medical Group entirely, you should
contact our Customer Service department. PacifiCare
will approve your request, if the Primary Care Physician
you’ve selected is accepting new patients and meets
the other criteria in Section 1. Getting Started: Your
Primary Care Physician. This includes being located
within 30 miles of your Primary Residence or Primary
Workplace.
In addition, you must meet the following criteria:
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Changing Your Doctor or Medical Group
You are not an inpatient in a hospital, a Skilled
Nursing Facility or other medical institution;
Your pregnancy is not high-risk or has not reached
the third trimester; and
The change isn’t likely to adversely affect the quality
of your health care.
PacifiCare reviews these requests on a case-by-case
basis. If you meet these requirements and call us by
the 15th of the current month, your transfer will be
effective on the first day of the following month. If
you meet the criteria but your request is received after
the 15th of the current month, your transfer will be
effective the first day of the second succeeding month.
For example, if you meet the above requirements and
you call PacifiCare on June 12th to request a new
doctor, the transfer will be effective on July 1st. If you
meet the above requirements and you call PacifiCare
on June 16th, the transfer will be effective August 1st.
If you are hospitalized, confined in a Skilled Nursing
Facility, being followed by a Case Management program
or receiving acute institutional or noninstitutional
care at the time of your request, a change in your
Primary Care Physician or Participating Medical Group
will not be effective until the first day of the second
month following your discharge from the institution
or termination of treatment. When PacifiCare’s Case
Management is involved, the Case Manager is also
consulted about the effective date of your Physician
change request.
If you are changing Participating Medical Groups, our
Customer Service department may be able to help
smooth the transition. At the time of your request,
please let us know if you are currently under the care
of a specialist, receiving home health services or using
durable medical equipment such as a wheelchair,
walker, Hospital bed or an oxygen-delivery system.
Please Note: PacifiCare does not advise that you
change your Primary Care Physician if you are an
inpatient in a hospital, a Skilled Nursing Facility or
other medical institution or are undergoing radiation
or chemotherapy, as a change may negatively impact
your coordination of care.
If you wish to transfer out of your Participating
Medical Group and you are an inpatient in a hospital,
a Skilled Nursing Facility or other medical institution,
the change will not be effective until the first day of
the second month following your discharge from the
institution.
If you are pregnant and wish to transfer out of your
Participating Medical Group and your pregnancy is
high-risk or has reached the third trimester, to protect
your health and the health of your unborn child,
PacifiCare does not permit such change until after the
pregnancy.
If you change your Participating Medical Group,
authorizations issued by your previous Participating
Medical Group will not be accepted by your new
group. Consequently, you should request a new
referral from your new Primary Care Physician within
your new Participating Medical Group, which may
require further evaluation by your new Participating
Medical Group or PacifiCare
Please note that your new Participating Medical Group
or PacifiCare may refer you to a different Provider than
Questions? Call the Customer Service Department at 1-800-624-8822. 15
PART A