CALIFORNIA - Pacificare Health Systems

Uniformed Services Employment and
Reemployment Rights Act 110
Section 9. Overseeing Your Health
Care 111
How PacifiCare Makes Important Health Care
Decisions 111
Authorization, Modification and Denial of
Health Care Services 111
PacifiCare’s Utilization Management Policy 112
Medical Management Guidelines 112
Technology Assessment 112
Utilization Criteria 112
What To Do If You Have a Problem 113
Appealing a Health Care Decision 113
Quality of Care Review 114
The Appeals Process 114
Expedited Review Process 114
Voluntary Mediation and Binding Arbitration 114
Voluntary Mediation 114
Binding Arbitration 115
Experimental or Investigational Treatment 116
Independent Medical Review 116
Eligibility for Independent Medical Review 116
Independent Medical Review Procedures 117
Review by the Department of Managed
Health Care 120
Complaints Against Participating Medical
Groups, Providers, Physicians and Hospitals 120
Section 10. General Information 123
What should I do if I lose or misplace my
membership card? 123
Does PacifiCare offer a translation service? 123
Does PacifiCare offer hearing and speechimpaired
telephone lines? 123
How is my coverage provided under extraordinary
circumstances? 123
How does PacifiCare compensate its
Participating Providers? 123
Table of Contents
How do I become an organ and tissue donor? 124
How can I learn more about being an organ
and tissue donor? 124
How can I participate in PacifiCare’s Public
Policy Participation? 124
Section 11. Definitions 126
Answering Questions 134
Secure Horizons ® Group Retiree Medicare
Advantage (MA) Plan 135