CALIFORNIA - Pacificare Health Systems

Providers listed in the directory, please call
Customer Service or visit our Web site at www.
securehorizons.com.
For twenty-four (24)-hour Emergency and/or
Urgent Care telephone numbers, refer to either
the Secure Horizons Group Retiree MA Plan
Provider Directory or your membership card.
Notices
Any notice required to be given under
this Combined Evidence of Coverage and
Disclosure Information shall be in writing and
either delivered personally or by United States
mail at the addresses set forth below or at such
other address as the parties may designate:
If to PacifiCare:
PacifiCare
Attn: Customer Service
P. O. Box 489
Cypress, California 90630-0489
If to you, to your last address known to
PacifiCare.
Technology Assessment
PacifiCare regularly reviews new procedures,
devices and drugs to determine whether
or not they are safe and efficacious for
Secure Horizons Group Retiree Medicare
Advantage Plan Members. New procedures
and technology that are safe and efficacious
are eligible to become Covered Services. If the
technology becomes a Covered Service, it will
be subject to all other terms and conditions of
the plan, including Medical Necessity and any
applicable Member Copayments, deductibles or
other payment contributions.
In determining whether to cover a service,
PacifiCare uses proprietary technology
guidelines to review new devices, procedures
and drugs, including those related to
behavioral health. When clinical necessity
requires a rapid determination of the safety and
efficacy of a new technology or new application
of an existing technology for an individual
Member, a PacifiCare Medical Director makes
a Medical Necessity determination based on
individual Member medical documentation,
Section 12 – General Provisions
review of published scientific evidence and,
when appropriate, seeks relevant specialty or
professional opinion from an individual who
has expertise in the technology.
Practitioners and Utilization Review
Utilization Review decision-making is based
only on appropriateness of care, service and
existence of coverage. PacifiCare does not
compensate practitioners or other individuals
conducting utilization review for denials of
coverage or service. Financial incentives for
Utilization Review decision-makers do not
encourage denials of coverage or service.
How PacifiCare’s Contracting Providers
Are Compensated
The following is a brief description of how
PacifiCare pays its Contracting Medical
Providers:
PacifiCare typically contracts with medical
groups/IPAs to provide medical services and
with Hospitals to provide Hospital services
to Members. The Contracting Medical
Groups/IPAs, in turn, employ or contract with
individual Physicians.
Most of the Contracting Medical Groups/IPAs
receive an agreed-upon monthly payment from
PacifiCare to provide services to Members. The
monthly payment may be either a fixed dollar
amount for each Member or a percentage
of the Monthly Plan Premium received by
PacifiCare. The monthly payment typically
covers professional services directly provided
by the Contracting Medical Group/IPA and may
also cover certain Referral services. Some of
PacifiCare’s Network Hospitals receive similar
monthly payments in return for arranging
Hospital services for Members. Other Hospitals
are paid on a discounted fee-for-service or fixed
charge per day of hospitalization.
Each year, PacifiCare and the Contracting
Medical Group/IPA agree on a budget for the
cost of services covered under the program
for all Secure Horizons Group Retiree MA Plan
Members treated by the Contracting Medical
Group/IPA. At the end of the year, the actual
cost of services for the year is compared to
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