CALIFORNIA - Pacificare Health Systems

Write: PacifiCare Appeals and Grievance Unit
5757 Plaza Drive Cypress, CA 90630
Fax: 1-714-503-7539 Attention: Appeals
and Grievance Unit
Walk-in: PacifiCare Customer Service Center
5701 Plaza Drive
Cypress, CA, 90630
Business Hours: 9:00 a.m. - 5:00 p.m.
Monday through Friday
How Your Expedited/72-Hour
Reconsideration Request Will Be
Processed
1. Upon receiving your reconsideration
request, PacifiCare will determine if your
request meets the definition of Time-
Sensitive.
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Section 9 – Organization Determination,
Appeals and Grievance Procedures
If your request does not meet the
definition, it will be handled within the
standard review process (thirty (30)
days for Appeals). You will be informed
by telephone that your request for
the expedited seventy-two (72)-hour
Appeal 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’s decision to process your
request within the standard time
frame, you may file a Grievance with
PacifiCare. The written confirmation
letter will include instructions on how
to file an expedited Grievance. If your
request is Time-Sensitive, you will be
notified of PacifiCare’s Appeal decision
within seventy-two (72) hours. You will
also receive a follow-up decision letter
within three (3) calendar days of the
telephone call.
An extension up to fourteen (14)
calendar days is permitted for a
seventy-two (72)-hour Appeal if
the extension of time benefits you,
for example, if you need time to
provide PacifiCare with additional
information or if PacifiCare needs
to have additional diagnostic testing
completed. PacifiCare will make a
decision as expeditiously as your health
requires, but no later than the end of
any extension period. If the time frame
is extended, you will be notified of the
reasons for the delay and informed
of your right to file an expedited
Grievance should you disagree with an
extension.
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 may
request a fourteen (14)-day extension if
obtaining necessary medical information
from the Provider will benefit you.
3. PacifiCare will make a decision on the
Appeal and notify you of it within seventytwo
(72) hours of receipt of your request.
If PacifiCare decides to uphold the original
adverse determination, either in whole
or in part, PacifiCare will forward the
entire file to the Independent Review
Entity for review no later than twentyfour
(24) hours after PacifiCare’s decision.
The Independent Review Entity will send
you a letter with their decision within
seventy-two (72) hours of receipt of your
case from PacifiCare, or at the end of the
fourteen (14)-day extension.
There are four possible dispositions to a
request for expedited Appeals:
Your request to expedite an Appeal
decision is accepted, PacifiCare makes a
decision in seventy-two (72) hours and
notifies you that the care will be arranged
or continued.
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