«Partnership HealthPlan of California Medi-Cal Member Handbook Together for your Health Our Service Area Del Norte, Humboldt, Lake, Lassen, Marin, ...»
Timely Access to Specialty Care When you call your specialist’s office to schedule an appointment, you should get an appointment within 15 business days (about 3 weeks) from the date of your call, unless it’s an urgent or emergency situation. If you need help contacting your specialist or making your appointment, call PHC’s Member Services Department.
If you have trouble getting an appointment, or you are told that it will take a long time to get an appointment, call PHC’s Member Services Department for help.
Services that require Prior Approval from PHC Some services must be approved by PHC before you can receive them. We call this Prior Approval or Prior Authorization.
Medical Equipment (e.g. wheelchairs) Medical Supplies (e.g. diapers) Certain Medications Non-Emergency Hospitalization Skilled Nursing Care If you need one of these services, your medical provider must get Prior Approval from PHC before providing the service. To do this, your provider must send a request for Prior Approval to PHC.
If a request for Prior Approval is denied by PHC, PHC will tell you and your provider. If you disagree with our denial, you can call PHC’s Member Services Department to request an appeal or State Hearing.
To learn more about filing an appeal or asking for a State Hearing, please see Section 12 of this Handbook.
Hospital Care If you need to be hospitalized, your PCP will make the hospital arrangements for you.
Some members are assigned to a hospital. If you are admitted to another hospital, in most cases you will be transferred to your assigned hospital if your provider has decided that you are stable for transfer and has approved your transfer to your assigned hospital.
What is a Second Opinion?
You have the right to get a second opinion at no cost to you. A second opinion is a visit with
another provider when:
You do not agree with your PCP or specialist’s treatment plan. (A treatment plan is the care your provider thinks you need.) You have questions about a diagnosis for your condition, given to you by your PCP or specialist.
You would like to make sure your treatment plan is the right one for you.
You can ask your PCP or specialist for a referral to another provider for a second opinion. The second opinion must come from a qualified health care professional in PHC’s network.
A qualified health care professional is a provider who has the training and experience to treat or review a specific medical condition.
How do I get a Second Opinion?
Talk to your PCP, specialist or PHC’s Member Services Department and let them know you want to see another provider. Be sure to tell them why you want to see another provider.
Your PCP, specialist or PHC will help refer you to a provider for a second opinion.
Call the second opinion provider to make an appointment.
Show your PHC ID card at the second opinion provider’s office.
You have the right to file a grievance if PHC denies your request for a second opinion or if you do not agree with the second opinion. You can learn more about what a grievance is and how to file a grievance in Section 12 of this Handbook.
New Technology New Technology is a change or advancement in health care. PHC’s medical staff studies new treatments, medicines, procedures and devices. Usually New Technology is not covered by Medi-Cal or PHC, but your provider can ask PHC to look at a request for coverage of New Technology.
If you would like PHC to look at a request for coverage of New Technology, ask your PCP or specialist to ask for Prior Approval from PHC. PHC will look into information about the New Technology, including the recommended use and safety of the New Technology. After review by medical specialists, PHC will let you know if the request will be approved or denied.
Learn about getting mental health care from our network.
This section talks about the type of mental health care services you can get with PHC.
PHC works with a company called Beacon Health Strategies (“Beacon”) to provide outpatient mental health services for mild to moderate mental health conditions. For more information on mental health please refer to Section 9 of this handbook.
Timely access to Outpatient Mental Health Care
Call Beacon at (855) 765-9703 to help find a mental health specialist in your area. When you call that mental health specialist’s office to schedule an appointment, you should get an appointment within 10 business days (about 2 weeks) from the date of your call. If you don’t get the help you need from Beacon, you should call PHC’s Member Services Department at (800) 863-4155.
Specialty Mental Health Services
Specialty Mental Health Services for the treatment of severe mental health conditions are provided by county mental health plans and are not covered by PHC or Beacon. Beacon will help coordinate your mental health care services whether they are offered by PHC or the county mental health plan. If you are receiving Specialty Mental Health Services, you can continue to get these services with the county mental health plan.
Learn about how and where to get urgent and emergency care.
If you think you have a medical emergency, call 911 or go to the nearest hospital.
If you want to speak with a nurse about your symptoms, call PHC’s Advice Nurse 24 hours a day, 7 days a week at (866) 778-8873.
If you are assigned to Kaiser Permanente (KFHP), call the Kaiser Advice Nurse at (800) 464-4000.
This free service can be used when you have medical questions and are not able to reach your medical provider, or if you aren’t sure if you should go to the emergency room.
We ask that you call your provider’s office if their office is open at the time of your call.
Do you need medical advice?
We know it can be hard to tell what kind of care you need. PHC has an Advice Nurse that can
help you. Here are some examples of how the Advice Nurse can help:
They can answer questions about a health concern and let you know if self-care at home is better for you.
They can give advice about whether you should get medical care, and how and where you should get that care.
They can tell you what to do if you need care and your PCP’s office is closed.
You can call the Advice Nurse 24 hours a day, 7 days a week by calling (866) 778-8873. A trained person may ask you questions to help direct your call.
What is the difference between Urgent and Emergency care?
Urgent and Emergency care are not the same thing. Urgent care is when you have a condition, illness or injury that is not life-threatening, but needs medical care right away. Many of PHC’s providers have urgent care hours and options, even at night and on the weekends.
How to get Urgent Care Call your PCP. You may speak to someone who answers calls for your PCP when the office is closed.
Ask to speak to your PCP or the provider on call. Another provider may take your call when your PCP is not available.
Tell the provider about your condition and follow their instructions.
You can call our Advice Nurse at (866) 778-8873, 24 hours a day, 7 days a week.
Timely access to Urgent Care You may receive same-day urgent care services. It should not take longer than 48 hours from the time of your call to get an appointment for urgent care from your PCP.
If you are outside of your Home County, you do not need to call your PCP or get Prior Approval before getting urgent care. Be sure to let your PCP know you got urgent care from another provider. You may need follow-up care from your PCP.
How to get Emergency Care Emergency care may be covered in Canada and Mexico when you are admitted to the hospital Emergency care is also covered anywhere in the United States and its territories:
American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and US Virgin Islands An emergency medical condition is a condition that you feel could lead to disability or death if not immediately treated. It can also be a condition that is causing you severe pain, or is quickly getting worse.
Examples of emergencies include, but are not limited to:
You can get emergency care, 24 hours a day, 7 days a week at any emergency room without Prior Approval.
If you need to go to the emergency room, take your PHC insurance card (and other insurance card if you have one, such as your red, white and blue Medicare card, or your Kaiser Permanente ID card if you have KFHP). You should always call your PCP after your visit to the emergency room for follow-up care.
Emergency services and care include transportation, medical screening, examination and evaluation by a provider or appropriate personnel for both physical and psychiatric emergency conditions.
Thoughts or actions about hurting yourself or someone else Unable to care for yourself, such as being unable to feed, shelter or dress yourself due to a mental disorder What to do in the case of an emergency If you think you have a medical emergency, call 911 or go to the nearest hospital You are not required to call your provider before you go to the emergency room Do not use the emergency room for routine (regular) health care Getting emergency care outside of your Home County If you have an emergency when you’re not in your Home County, you can get emergency services at the nearest emergency room. Emergency services do not require Prior Approval from PHC or your PCP.
If you are admitted to a hospital not in PHC’s network, or to a hospital your PCP does not work with, PHC has the right to move you to a hospital that works with PHC as soon as it is medically safe to do so.
You may need hospital care after an emergency to stabilize your condition. This is called “poststabilization” care. The hospital will call PHC to ask for Prior Approval. Show the hospital your PHC ID card. If you don’t have your ID card, ask the hospital to call PHC.
Your PCP must provide follow-up care when you leave the hospital.
Not sure if you have an emergency?
Call your PCP if you are not sure if you are having an emergency. Do what your PCP tells you to
do. Non-emergency problems can include, but are not limited to:
What kinds of transportation are there?
There are three types of transportation that we will talk about in this section of the Handbook.
Each type of transportation has its own rules and requirements.
Emergency medical transportation Emergency medical transportation is when you are taken by ambulance or helicopter (air ambulance) to a hospital for an emergency condition. You do not need Prior Approval for Emergency Transportation. If you have questions about Emergency Care, see Section 7 of this Handbook.
If you think you are having an emergency, call 911 or go to the nearest hospital. If you aren’t sure if your medical condition is an emergency, call your PCP or call the Advice Nurse at (866) 778-8873. If you are assigned to Kaiser Permanente (KFHP) call (800) 464-4000.
Non-emergency medical transportation You can use non-emergency medical transportation (NEMT) when you cannot get to your medical appointment by car, bus, train, or taxi, and the plan pays for your medical or physical condition.
NEMT is an ambulance, litter van or wheelchair van. NEMT is not a car, bus, or taxi. PHC allows the lowest cost NEMT for your medical needs when you need a ride to your appointment.
That means, for example, if a wheelchair van is able to transport you, PHC will not pay for an ambulance.
NEMT can be used when:
• Medically needed;
• You can’t use a bus, taxi, car or van to get to your appointment;
• Requested by a PHC provider; and
• Approved in advance by PHC.
To ask for NEMT, please call PHC’s Care Coordination Department at (800) 809-1350 at least one business day (Monday-Friday) before your appointment. Or call as soon as you can when you have an urgent appointment. Please have your member ID card ready when you call.
Limits of NEMT:
You may use NEMT if you meet the terms above.
Getting to your medical appointment by car, bus, taxi, or plane. Transportation will not be provided if the service is not covered by PHC. A list of covered services is in this member handbook.
If you are being taken from a hospital to a Skilled Nursing Facility (also called Long Term Care) your provider does not need Prior Approval from PHC. If the transportation is for another reason, your provider needs Prior Approval from PHC.
Non-emergency medical transportation is covered with Prior Approval from PHC for transportation to any covered Medi-Cal service. This includes some services that are not
provided by PHC. Some examples are:
Specialty mental health care provided by your Home County (if prescribed by your specialty mental health provider) Dental care provided by your dentist (if prescribed by your dental provider) Dialysis provided at a dialysis center (if prescribed by your provider)
Cost to Member:
There is no cost when transportation is authorized by PHC.
Non-medical transportation You can use non-medical transportation (NMT) when you are getting to and from a medical appointment for a screening and/or needed treatment service covered under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program1.