PacifiCare of Oklahoma, Inc.

Transcription

1 PacifiCare of Oklahoma, Inc. Welcome to PacifiCare When you chose PacifiCare as your health care plan, you opened the door to many benefits, services and resources designed to keep you healthy. This booklet can help you get the most out of your new PacifiCare health care plan. It explains how you can choose your Primary Care Physician, use urgent and emergent care services, transfer your medical records and much more. Welcome to PacifiCare. 1

2 TABLE OF CONTENTS Accessing Behavioral Health Services... 4 Important Family Information... 4 Welcome to a New Choice in Health Care Coverage... 5 Your PacifiCare Plan... 5 Your Medical Group... 6 How to Get the Most From Your PacifiCare Plan... 6 Questions? Concerns? Suggestions?... 7 Your PacifiCare Member ID Card... 8 Your Identification Card... 8 If You Want to Make a Change... 9 Choosing a New Physician... 9 Changing Contracting Medical Group or Primary Care Physician... 9 Making an Appointment... 9 After Hours If You Need an Appointment Right Away If You Go to the Hospital Home Care When You Need Specialty Care When You Need Urgent Care Urgent Care In-Area Out-of-Area When It s an Emergency If You re in an Accident About Your Medical Information Using Your Behavioral Health Benefits PacifiCare Behavioral Health Maintains Confidentiality Questions and Answers About Behavioral Health Biologically Based Mental Illness Quality Health Improvement Programs Your Copayment Maximum Who Is Eligible for PacifiCare Benefits? You Your Spouse Your Children When Are You Covered? If You Stop Working: The Individual Conversion Plan and COBRA When Benefits May Be Lost or Denied When Coverage Stops If You Are in the Hospital When Coverage Ends Changes to Your PacifiCare Plan Renewals and Rate Changes If You Receive a Bill If a Claim Is Denied Who s Responsible in the Event of Nonpayment When You re Covered by More Than One Plan Third-Party Liability If You re Injured on the Job Your PacifiCare Plan and Medicare

3 How to Voice a Complaint or Request an Appeal Complaint Resolution Procedures Member Satisfaction Hearing Binding Arbitration Complaint Log Advance Directives Advance Directives What Is an Advance Directive? What Is a Living Will? What Is a Health Care Proxy? What Is an Oklahoma Do-Not-Resuscitate (DNR) Order? Do I Have to Write an Advance Directive Under the Law? Can I Change My Mind After I Write a Living Will, DNR Order or Appoint a Health Care Proxy? What If I Fill out an Advance Directive in One Sate and Am Hospitalized in a Different State? What Should I Do With My Advance Directive If I Choose to Have One? How Can I Get More Information About Advance Directives? Technology Assessment Committee Commonly Asked Questions and Answers Definitions PacifiCare Member Rights and Responsibilities As a PacifiCare Member, You Have the Right to As a PacifiCare Member, You Have the Responsibility to

4 Accessing Behavioral Health Services 1. All behavioral health services, except emergencies, must be preauthorized by PacifiCare Behavioral Health. To access your behavioral health services, call PacifiCare Behavioral Health at (800) , available 24 hours a day, seven days a week. 2. Billing of Claims Inquiry: (800) PacifiCare Behavioral Health Claims Avenida de la Carlota, Suite 700 Laguna Hills, CA Important Family Information To reach help quickly when you need medical care, we recommend that you write important family information here and keep this booklet easily accessible. Medical Group and Primary Care Physician Pediatrician 4

5 Welcome to a New Choice in Health Care Coverage. YOUR PACIFICARE PLAN PacifiCare is different from other health benefit plans. With PacifiCare, you get a wide range of services to meet your health care needs from preventive care to routine doctor visits, from care while you re in the hospital to care after you leave. You and your family get all this for a single monthly premium. You also get access to a large network of contracting doctors, hospitals and other health care providers. You can see these providers whenever you need medical care. You are covered 24 hours a day, every day of the year. Before you see a doctor, you will need to choose a Primary Care Physician from the list of physicians in the Provider Directory. You may have already done this when you enrolled. Feel free to choose any available Primary Care Physician from the list. You and each member of your family may choose the same Primary Care Physician, or you may have different doctors. Your Primary Care Physician will direct all of your medical care to see that you get the care you need when you need it, whether the care is delivered in the doctor s office, in another outpatient facility or in a hospital. He/she will also authorize any specialty care you may need to ensure the continuity of your health care. All inpatient and outpatient services, except emergency and urgent care services, must be preauthorized by your Primary Care Physician at a contracting facility. And if you require medical care in an emergency or when you are away from home, be sure to contact your Primary Care Physician as soon as possible. Be sure to let your Primary Care Physician know your health plan is PacifiCare every time you call or visit your doctor s office. Your relationship with your Primary Care Physician is an important one. That is why we strongly recommend that you choose a Primary Care Physician close to your home. Having your Primary Care Physician nearby makes receiving medical care and developing a trusting and open relationship much easier. Once you have chosen your Primary Care Physician, we recommend that you have all your medical records transferred to his/her office. This will give your Primary Care Physician access to your medical history and make him or her aware of any existing health conditions you may have. Always ask to see your Primary Care Physician when you make an appointment. Your Primary Care Physician is responsible for all your routine health care services and he or she should be the first one you call with any health concerns. When you select a Primary Care Physician it is important to remember that this limits you to the panel of Specialists who are affiliated with your Primary Care Physician s network. You may contact Customer Service if you have special needs and require assistance in accessing health care services. 5

6 YOUR MEDICAL GROUP PacifiCare contracts with local medical groups. These groups of physicians are responsible for delivering quality medical care to PacifiCare Members. When you choose one of these contracting medical groups or physicians, you agree to honor the operating policies of the medical group and physicians. They are there to help you get the care you need, and need your help to ensure that your care is delivered in the right environment and at the right time. Your medical group also has staff on hand to help you get the most from your health care. Their staff can help you select your Primary Care Physician, provide information about your Primary Care Physician or Specialist, and can respond to questions regarding services you receive at the group. In addition, you can obtain information about your physician(s) by contacting: For MDs: The Oklahoma Board of Medical Licensure and Supervision at (405) or by at For DOs: The Oklahoma Board of Osteopathic Examiners at (405) or by at We encourage you to get to know the staff at your medical group on or before your first visit. They can help you with any questions or concerns about your medical care. If you have questions about your health care benefits, call the PacifiCare Customer Service Center at (800) HOW TO GET THE MOST FROM YOUR HEALTH PLAN 1. See or call your Primary Care Physician first for all your medical care. Your doctor will see that you get the care you need, whether in his or her office or from another doctor. 2. If you or a covered member of your family need same-day urgent care, call your Primary Care Physician s office for medical direction. NOTE: Use of emergency medical facilities for urgent care services that would not result in serious jeopardy to your health, the health of your unborn child, serious impairment of bodily functions or dysfunction of bodily organs must be preauthorized by your Primary Care Physician, or the services may not be covered. 3. If you need emergency care, go immediately to the nearest medical facility for care. Then call your doctor s office as soon as possible or within 48 hours of receiving the care. Emergency care is covered when it is for a medical emergency. An emergency is based on your presenting symptoms arising from any injury, illness or condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable and prudent layperson could expect the absence of medical attention to result in 1) serious jeopardy to the patient s health (or in the case of a pregnant woman, serious jeopardy to the health of the fetus); 2) serious impairment to bodily function; or 3) serious dysfunction of any bodily organ or part. 6

7 Follow-up care after an emergency is also covered when provided or arranged by your Primary Care Physician. QUESTIONS? CONCERNS? SUGGESTIONS? Your PacifiCare Customer Service Center is here to help. Call (800) , 8 a.m. to 6:30 p.m., Monday through Friday. 7

8 Your PacifiCare Member ID Card A PacifiCare Member ID card for you and each member of your family covered by the PacifiCare plan is included in this package. This card is the key to all your health care benefits, so it s important that you carry it with you at all times. When making an appointment with any contracting provider, be sure to identify yourself as a PacifiCare Please review your ID card to make sure all the information is correct, including the name of your chosen Primary Care Physician. If information on your card is not correct, if you need to order a new card or have questions about your ID card, call PacifiCare s Customer Service Center at (800) Member, and remember to show your ID card whenever you receive medical care. It contains valuable information about your benefits. YOUR IDENTIFICATION CARD Front Back 1. Member s name 2. Member s identification number 3. Employer group identification number 4. The selected Primary Care Physician or medical group 1. Routine and urgent care information 2. What to do in case of life-threatening emergency 3. How to reach PacifiCare Customer Service, including phone number, office hours and Claims address. 5. PCP effective date 6. PCP phone number 7. Copayment and benefit information 8. Behavioral Health authorization phone number. 8

9 If You Want to Make a Change CHOOSING A NEW PHYSICIAN As a PacifiCare Member, you will receive health care services from a Primary Care Physician. Primary Care Physicians include doctors trained primarily in Family Practice, Internal Medicine and Pediatrics. When you joined PacifiCare, you and each member of your family chose one of these doctors as your personal physician. If you ever want to change your choice of physician, contact the PacifiCare Customer Service Center at (800) The change will be effective the first of the next month if you call by the 20 th of the current month. If you call after the 20 th of the month, your change will be effective the first day of the second month following your request. You can choose a new physician within your current medical group or switch to another medical group altogether, as long as it is listed in PacifiCare s Provider Directory. And remember, each member of your family can have the same doctor or you can each choose individually. PacifiCare believes the relationship between patient and physician is a special one. It develops over time, as trust and familiarity grow. Your doctor will manage all your health care needs to see that you receive a treatment plan that s best for you. Ask to see your personal Primary Care Physician whenever you call for an appointment. Your doctor is responsible for all your treatment, including referrals to specialists. CHANGING CONTRACTING MEDICAL GROUP OR PRIMARY CARE PHYSICIAN To change your choice of medical group, simply call the PacifiCare Customer Service Center at (800) The change will be effective the first of the month if you call by the 20 th of the current month. There are a few things to know when you choose a new medical group or PCP: If you are in the hospital, you cannot change to a new medical group or PCP until after you have been discharged. The change will be effective the first of the month following a full 30 days after you leave the hospital. You cannot return to your previous medical group for one year from the time you left the group. When you change medical groups, you also change to the network of specialists that contracts with the new medical group. We recommend against changing PCPs or Medical Groups if one or more of the following circumstances exist: The change could have an adverse affect on the quality of your health care. If you are an organ transplant candidate. If you have an unstable, acute medical condition for which you are receiving active medical care. If you are in your third trimester of your pregnancy. Making an Appointment When you are ready to make an appointment to see your Primary Care Physician, call your doctor s office at the number listed on the front of your PacifiCare ID card. Please call in advance for routine, non-emergency appointments and health evaluation appointments. 9

10 Making an appointment will allow you and your doctor enough time to talk about your needs. If you are a new member to PacifiCare, or to the physician, please let the office staff know so they may prepare any paperwork necessary for your medical records. If your doctor orders laboratory or X-ray tests, show your PacifiCare ID card when you arrive at your appointment for the services. IF YOU MUST CANCEL AN APPOINTMENT, CALL YOUR PHYSICIAN AS FAR IN ADVANCE AS POSSIBLE. After Hours If you need to talk to or see your Primary Care Physician after the office has closed for the day, call the 24-hour number located on your PacifiCare membership card. The Physician on call will return your call and advise you on how to proceed. If You Need an Appointment Right Away If you have an urgent medical illness or injury that can t wait for a regular appointment, call your Primary Care Physician s office. If your Primary Care Physician is not available at the time, you may ask to see another physician in that office. The doctor may arrange to see you immediately, give you medical advice or set up an appointment for you. If You Go to the Hospital When you need to go to the hospital, your Primary Care Physician will arrange for you to stay at a hospital where your doctor is on staff. Your hospital care is covered for your copayment, if you have one. This includes a semiprivate room, tests and physician visits while in the hospital. See your Plan Benefits brochure for copayment information. Home Care Your Primary Care Physician may decide to have a nurse visit you at home rather than keep you in the hospital. Home care is covered only when authorized by your Primary Care Physician. When You Need Specialty Care Your Primary Care Physician (PCP) is the person you will see first for your medical care. In most cases, your doctor will be able to take care of your medical problem. But if your Primary Care Physician believes a specialist is needed to treat your medical condition, he or she will make the referral on your behalf. Sometimes, your Primary Care Physician may consult with other physicians who are members of a Patient Care Committee at your medical group. This committee allows Primary Care Physicians to discuss special medical situations with colleagues. The committee shares knowledge and experiences to recommend the course of care appropriate for you. 10

11 Your Primary Care Physician decides whether to refer you to a specialist or try other medical therapy. As the coordinator of your personal medical care, your Primary Care Physician will work with you to determine a treatment plan. With your PCP s referral, you can see a specialist. Most specialty care will be provided within your medical group. After your PCP makes the referral, you are responsible for making the actual appointment with the specialist. Charges for approved services from a specialist are billed directly to the medical group or PacifiCare. If you ever receive a bill for treatment by a referred specialist, send it to: PacifiCare Claims Department P.O. Box San Antonio, TX To see a specialist: See your Primary Care Physician first. If your doctor feels you need to see a specialist, he or she may consult with your medical group s Patient Care Committee. The Primary Care Physician may decide to approve the referral or suggest an alternate treatment plan. If your doctor approves an ongoing referral to a specialist and you then change your Primary Care Physician, you must have your specialty care reviewed and approved by your new Primary Care Physician. Physician, you may be responsible for paying for the services. When You Need Urgent Care URGENT CARE Urgent care is defined as medically necessary and immediately required as a result of an unforeseen illness, injury, or condition. IN-AREA Urgent care is a covered benefit, subject to scheduled copayments. HOWEVER, USE OF THE EMERGENCY ROOM FOR URGENT CARE SERVICES THAT ARE NOT PREAUTHORIZED BY A CONTRACTING PHYSICIAN MAY NOT BE COVERED. 1. If you need urgent medical care, CALL YOUR PRIMARY CARE PHYSICIAN S OFFICE and inform them that you are a PacifiCare Member. 2. Inform your PCP or office personnel that you have an urgent medical problem and need assistance, and describe your condition or symptoms. 3. During office hours, your call will be given to your physician or a medical staff person who will give you instructions. 4. After office hours, your Primary Care Physician s answering service will take your name and phone number. Your doctor or an on-call physician will call you back. You will be given medical direction at that time. Remember, if you see a specialist without an authorized referral from your Primary Care 11

12 OUT-OF-AREA Urgent care is a covered benefit, subject to scheduled copayments. HOWEVER, USE OF THE EMERGENCY ROOM FOR URGENT CARE SERVICES OUT-OF-AREA REQUIRES NOTIFYING YOUR PRIMARY CARE PHYSICIAN WITHIN 48 HOURS OR AS SOON AS POSSIBLE. 1. If you are traveling and require urgent care that cannot be delayed until you return to the PacifiCare service area, seek medical attention. 2. If you seek medical attention in an emergency room, you must notify, or take reasonable steps to notify your Primary Care Physician s office within 48 hours. You will be responsible for the appropriate emergency room copayment as shown in your Plan Benefits brochure (and on your ID card). 3. Forward any bills to PacifiCare for reimbursement. ALL FOLLOW-UP CARE MUST BE PROVIDED OR ARRANGED THROUGH YOUR PRIMARY CARE PHYSICIAN. When It s an Emergency Emergency care is a covered benefit. An emergency is based on your symptoms arising from any injury, illness or condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable and prudent layperson could expect the absence of medical attention to result in 1) serious jeopardy to the patient s health (or in the case of a pregnant woman, serious jeopardy to the health of the fetus); 2) serious impairment to bodily function; or 3) serious dysfunction of any bodily organ or part. If you or someone in your family needs emergency care, 1. Go to the nearest hospital emergency room or call Identify yourself as a PacifiCare Member. 3. Call your Primary Care Physician s office within 48 hours. Let your doctor know you have been treated in an emergency room. Remember, the condition must be an emergency. 4. If you are admitted to the hospital, your Primary Care Physician may arrange to transfer you to a contracting hospital associated with your medical group. 5. If you need preventive, routine or follow-up care after being treated in an emergency room, the care must be arranged or provided by your Primary Care Physician. If you receive emergency care that is approved by your doctor, the services are covered for your emergency room copayment unless you are admitted as an inpatient. Your emergency room copayment is waived if you are admitted to the hospital. See your Plan Benefits brochure for your copayment. If you receive a bill, send it to: PacifiCare Claims Department P.O. Box San Antonio, TX If You re in an Accident If you are in an accident have no control over where you are taken following the accident, you must notify, or take reasonable steps to notify, your Primary Care Physician within 48 hours. There is a physician on call 24 hours a day to take your call. 12

13 About Your Medical Information You have the right to access your medical records. This access may be granted by contacting your Primary Care Physician. Additionally, the confidentiality and privacy of your medical records and personal information are protected by law. When transferring to a new Primary Care Physician or medical group, a signed medical release is required to transfer your medical records to your new provider. Your current physician s office can provide you with the medical release form. A routine consent is included on the application for enrollment. Medical records and/or information may be collected, and utilized for the purpose of clinical review, satisfaction and quality studies, complaint and/or appeal investigation, fraud detection and State, Federal or accreditation reviews. You have the right to approve or deny the release of identifiable personal information for disclosure beyond PacifiCare. Special consent forms include the reason for disclosure and use of the information, length of time for which the consent is valid, date and signature of the member. Confidential medical information will not be released or shared with another provider or practitioner, employer or broker without a written or signed release from you. Using Your Behavioral Health Benefits You can call PacifiCare Behavioral Health toll-free at (800) anytime 24 hours a day, seven days a week for a direct confidential referral, or your Primary Care Physician can request a referral on your behalf. When you call, you ll speak with a coordinator who ll check your eligibility and gather basic information about you and your situation. Depending on the type of help you need, a clinician may then talk with you about your problem and determine what provider and treatment would be best for you. If you re referred to a provider contracting with PacifiCare Behavioral Health, you ll be authorized for a specific number of visits for a specified period of time. If you want information about providers contracting with PacifiCare Behavioral Health or to obtain access to Behavioral Health benefits, please call PacifiCare Behavioral Health at PACIFICARE BEHAVIORAL HEALTH MAINTAINS CONFIDENTIALITY You can be sure what you discuss with our behavioral health staff is kept strictly confidential. We provide information only to the professionals delivering your treatment. Confidentiality is built into PacifiCare Behavioral Health s operations through a system of control and security that protects written and computer-based information. All contracting physicians and providers are required to enforce and adhere to all State and Federal confidentiality requirements. 13

14 QUESTIONS AND ANSWERS ABOUT BEHAVIORAL HEALTH Q Is Preauthorization Always Necessary to Start a Treatment Program? A Yes, all benefits must be preauthorized by PBH, except in an emergency, in which case you should first do everything possible to ensure your physical safety, then call PBH within 24 hours of admission, or as soon as reasonably possible. Q What Happens in an Emergency? A Our first concern is for your health and well being. If faced with an emergency, do everything possible to ensure your physical safety, which may include calling 911. Get to a treatment center first, then, within 24 hours of the admission or as soon as reasonably possible, call PacifiCare Behavioral Health at (800) , which is available 24 hours a day, seven days a week. Please see the Emergency and Urgent Medical Care section for more specific information. PacifiCare Behavioral Health will coordinate all follow-up behavioral health services to emergency treatment on your behalf. This may include a transfer to a contracting provider designated by PacifiCare Behavioral Health when you are stable and the transfer would not create an unreasonable risk to your health. Q Can I Receive Care Outside the Service Area? A For behavioral health services outside the service area, you will be covered for Emergency Services only. Please see the Emergency and Urgent Medical Care section for more specific information. Q What Do I Do If I Receive a Claim? A All authorized services prescribed by PacifiCare Behavioral Health will be billed directly to PacifiCare Behavioral Health. However, if you get emergency treatment from a noncontracting provider, you may receive a bill. Send us a copy of the bill or claim within 90 days of the date of service, or as soon as possible. PacifiCare Behavioral Health will not pay for claims submitted after 120 days of the date of service. Mail bills to: PacifiCare Behavioral Health Claims Avenida de la Carlota, Suite 700 Laguna Hills, CA (800) If your plan includes copayments, you are responsible to pay these directly to the provider. Q How Are New Treatments and Technologies Evaluated? A We are committed to evaluating new treatments and technologies in behavioral health care. A committee composed of PacifiCare Behavioral Health s Medical Director and medical researchers meet at least once per year to assess technological advances and new programs. BIOLOGICALLY-BASED MENTAL ILLNESS Care for schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder and panic disorder shall be covered as any other physical illness and will not be subject to the limitations of Mental Health Services as described in your schedule of benefits. Quality/Health Improvement Programs 14

15 In addition to the comprehensive benefits you receive through our plan, PacifiCare offers the following health improvement programs, at no additional cost: Healthy Pregnancy Program is an interactive program that is designed to give moms and babies the best possible start by providing risk assessment and prenatal and baby care educational books. The StopSmoking Program is PacifiCare s awardwinning smoking cessation program. This personalized self-assistance program, which includes a self-care kit and telephone counseling for up to a full year, is available, free of charge. Taking Charge of Your Heart Health is a selfdirected, lifestyle management program for members with heart disease. The program focuses on diet, exercise, stress, tobacco use and self-care. Taking Charge of Diabetes is a self-directed intervention program that addresses the same lifestyle issues as above (diet, exercise, stress, tobacco use and self-care). Participants receive a wallet card to remind them to have preventive care done on a regular basis. Taking Charge of Asthma focuses on preventive care and self-management of asthma. Asthma education kits and peak flow meters are provided to members who request them. Taking Charge of Depression is a program designed to provide education and support for patients being treated for depression in the primary care setting. PacifiCare s Internet site provides further information about Health Improvement, and gives you important information such as provider directories, formulary listings, access to Customer Service and more. Visit our site at: A brochure describing PacifiCare s Quality Improvement Program is available upon request by contacting PacifiCare s Customer Service Center. For program enrollment or more information, call (800) Your Copayment Maximum We want to be sure that you receive the health care you need at a price you can afford, so we set an annual copayment maximum on each of our benefit plans. (Check your Plan Benefits brochure for your maximum.) If you reach your copayment maximum for the year, any eligible care you need for the rest of that calendar year will be covered without a copayment. The family copayment maximum is three times your individual maximum. The annual copayment maximum does not apply to supplemental benefits. Be sure to keep track of the copayments you pay. You are responsible for letting PacifiCare s Customer Service Center know when you reach your maximum. You will be asked to show proof of the copayments you have paid throughout the year. If you change PacifiCare benefit plans during the calendar year, the annual copayment maximum of the most current benefit plan will be applicable. Any copayment paid under the previous PacifiCare benefit plan will be applied to the current benefit plan fur purposes of determining if the maximum has been met. If the current annual copayment namimum is less than the previous maximum, you will not be entitled to a refund. You are responsible for your applicable copayment amount listed on your member ID card. To explain how copayments are calculated, Medicare sets 'allowable' reimbursement rates for a given range of services. This allowable amount is often the fundamental basis of our reimbursement to providers. Copays will be less than 50% of the Medicare reimbursement charge (as identified above) 15

16 for the specific service within a Medicare service area or less than 50% of the fee for service claim charge by the provider, whichever is less. 16

17 Who Is Eligible for PacifiCare Benefits? YOU You are eligible to enroll with PacifiCare if: You live or work in PacifiCare s service area. (See the Provider Directory for a listing of the service area.) You meet the eligibility requirements defined by your employer s group contract with PacifiCare. Since your employer contracts for your health care benefits, you are the subscriber to the health plan. Your spouse and children are dependents. YOUR SPOUSE Your spouse is eligible to enroll with PacifiCare if: He/she meets the dependent eligibility requirements defined by your employer group contract with PacifiCare. YOUR CHILDREN Students Your dependent unmarried children may continue as eligible dependents through the age specified by your employer if: They are full-time students registered at a certified college or university You provide proof of dependent status to PacifiCare on a periodic basis. Dependent students who live outside PacifiCare s service area are covered only for urgent care and emergencies. See page 10 of this handbook for more information. Newborns It is critical to choose your baby s pediatrician as early as possible in your pregnancy. This will help in your baby receiving uninterrupted care in the critical newborn period. Your baby is automatically covered for medically necessary care for 31 days from the date of birth. For the coverage to continue after that time, you must submit an application for enrollment to add the newborn to your policy within those first 31 days from the date of birth. Send your application through your employer. Adopted Children Adopted children are covered from the date of legal custody or the date placed in the home. For the coverage to be valid, you must submit an application for enrollment to PacifiCare within 31 days of the legal adoption or of when legal custody begins. New Dependents as a Result of Marriage If you marry and want to enroll new family members, they are covered from the date of your marriage as long as you submit an enrollment application within 31 days of the date of marriage. Please note that all applications for enrollment should always be submitted through your employer. When Are You Covered? You and your eligible dependents are covered as of 12:01 a.m. on the effective date of your Medical and Hospital Group Subscriber Agreement. Your employer must certify your eligibility by submitting your properly executed enrollment form as identified in the Medical and Hospital Group Subscriber Agreement. 17

18 If you are enrolling in the individual conversion plan, you are eligible as described below. If You Stop Working: The Individual Conversion Plan and COBRA If you stop working because of retirement, disability, leave of absence, temporary layoff or termination, talk to your employer about COBRA coverage. If you become ineligible for coverage because of termination of employment, divorce or the death of a spouse, or if your dependent child is no longer eligible because of age or marriage, see your employer about continuing your current benefits. For coverage to extend beyond your COBRA coverage or if your employer is not required to offer COBRA coverage, you can contact PacifiCare about the individual conversion plan. To convert to the plan, you must apply in writing to PacifiCare within 31 days of the time your coverage ends. When Benefits May Be Lost or Denied There are rare instances when you may not be able to use your PacifiCare benefits: When major disaster or epidemic causes demand for services beyond the capacity of available personnel or facilities. When circumstances beyond PacifiCare s control prevent delivery of services, such as complete or partial destruction of facilities, war, riot, disability of a significant part of personnel. In such situations, PacifiCare and its contracting providers will perform to the best of their abilities to provide services. If the service is medically necessary to prevent serious jeopardy to you or an unborn child, serious impairment of bodily functions, or serious dysfunction of an organ, you may go to the nearest medical facility. PacifiCare will reimburse the Member for the charges for the care. If you refuse medical services against the advice of your Primary Care Physician or specialty physician for any condition, illness or injury, PacifiCare may deny coverage of medical services for the condition if you have been informed of: 1. The reasons for such medical services, 2. The consequences if medical services are refused, and 3. The fact that the Primary Care Physician or specialty physician believes no medically acceptable alternatives exist. When Coverage Stops Coverage stops automatically when you are no longer eligible as defined by your employer or on the earliest of the following: The date your contract agreement terminates. If you or your employer fail to make a premium payment by the last day of the month for which a contribution has been paid. The last day of the month a dependent becomes ineligible. If your employment is terminated or you are no longer eligible through your employer, the last day of the 18

19 month for which the last payment was made for your coverage. The date you or a dependent enters military service. If a dependent enters military service, only that dependent is no longer covered. If you presented false information or permitted another person to use your PacifiCare ID card, the date either of those events occurred. If you receive a notice of violation and continue to act in a way that interferes with the effective delivery of medical care, on the first day of the month in which you receive notice of disenrollment. The last day of the month in which you permanently move outside PacifiCare s service area. If the subscriber dies, coverage for dependents ends on the last day of the month of the subscriber s death. PacifiCare may also deny coverage if: You do not pay copayments you owe to contracting providers. You do not pay for services delivered by contracting providers for which a fee is allowed but which are not covered in the Plan Benefits brochure. You refuse a prescribed treatment or procedure if the attending physician believes such treatment or procedure is necessary to restore and maintain health or maintain life. If your coverage is terminated because of nonpayment, misuse of your identification card or detrimental conduct, you are not eligible for continuation coverage. In all cases, if a dependent s coverage is terminated, it does not affect the coverage of other family members. If the subscriber s coverage stops, the membership of all dependents stops as well. Coverage ends at midnight on the day that the termination is effective. If You Are in the Hospital When Coverage Ends If you are in the hospital when you become ineligible for coverage and transfer to the PacifiCare conversion plan, you will receive the inpatient benefits of the PacifiCare group plan until you are discharged from the hospital. If your PacifiCare group coverage is ending due to termination of the agreement by your employer or your employer s participation in the agreement is terminated, you may not transfer to the conversion plan. If you are in the hospital for childbirth, you can continue to receive obstetrical care through delivery and discharge from the hospital if PacifiCare terminates the agreement with the employer. All benefits cease when you leave the hospital. Changes to Your PacifiCare Plan PacifiCare may change the Medical and Hospital Group Subscriber Agreement or any benefits after having given you at least 60 days written notice. PacifiCare must also tell you when the change will become effective. Your employer may cancel your Medical and Hospital Group Subscriber Agreement. Your employer will notify 19

20 you in writing of the cancellation at least 60 days before the contract expires. There may be a time when a physician is no longer part of the provider network. PacifiCare or your medical group will notify you within 30 days if this happens. You will be asked to select a new personal Primary Care Physician from the current Provider Directory. (See Choosing a New Physician on page 7.) If you do not choose a Primary Care Physician, PacifiCare will choose one for you. You can change your selected physician by notifying PacifiCare Customer Service Center at (800) PacifiCare or your employer may make changes to the Medical and Hospital Subscriber Agreement or Benefits without member consent or concurrence. The Medical and Hospital Subscriber Agreement prevails over any conflicting information. If you are eligible to elect medical and hospital coverage under the Medical and Hospital Group Subscriber Agreement or accept benefits presented in the agreement, and you decide to elect coverage, you agree to all stated terms, conditions and provisions. Your employer is responsible for notifying you in writing within 72 hours of any change to your PacifiCare Plan. Renewals and Rate Changes PacifiCare must provide your employer 30 days written notice before a rate change may take effect. PacifiCare and your employer contract for your benefits for a one-year period. Typically, the agreement is automatically renewed each year unless there is a change in benefits. PacifiCare will notify you if there are any material changes to the contract. If You Receive a Bill One of the benefits of being a PacifiCare Member is that there are virtually no claim forms to complete. Services prescribed by your Primary Care Physician will be billed directly to PacifiCare or your medical group, unless you are responsible for a copayment charge. However, if you receive medical care out of PacifiCare s service area or in an emergency room, you might receive a bill from those providers. If you ever receive a bill for medical care that is covered under your Medical and Hospital Subscriber Agreement and authorized by your Primary Care Physician, immediately send it to PacifiCare s Claims Department at the address found on the back cover of this handbook. If the bill is for out-of-area or emergency room care you already paid for, be sure to send the bill and proof of payment for reimbursement to PacifiCare within 120 days of the date of service. If you have any questions, contact PacifiCare s Customer Service Center. If a Claim Is Denied If you submit a claim for payment and any part of it is denied, PacifiCare will reconsider the claim. Send your written request to PacifiCare Customer Service within 18 months of the day it was denied. Be sure to include the reasons why you believe the denied claim should be paid based on the contents of your Medical Hospital and Group Subscriber Agreement. If you have any questions, call PacifiCare Customer Service at (800)

21 21

22 Who s Responsible in the Event of Nonpayment You Are Responsible for Payment of: Your copayments when covered services are provided by a contracting provider. The portion of the charges PacifiCare does not pay when services are provided by a physician or medical facility without an authorized referral from a contracting physician. The cost of services for benefits not included in the PacifiCare plan benefits offered by your employer. You Are Not Responsible for: Any amounts owed by PacifiCare to a provider for medical services covered by PacifiCare. When You re Covered by More Than One Plan If you have health care coverage in addition to your PacifiCare Plan either as a dependent or a subscriber you can coordinate the benefits to get the most coverage at the lowest cost to you. In fact, often you can coordinate benefits so that 100 percent of your health care costs are covered. Remember, even when PacifiCare is the secondary payer you must have your care authorized by your contracting Primary Care Physician. For information about coordination of benefits, call the PacifiCare Claims Department at (800) Third-Party Liability If you are injured through an act or omission of a third party (i.e., motor vehicle accident) and are entitled to recovery from a third party or your own liability carrier, including automobile medical payment coverage, that you (or your dependent) agrees that PacifiCare, or its designee,shall have a right of subrogation and reimbursement against your rights and/or proceeds of recovery for the cost of the benefits provided by PacifiCare or its designee. Reimbursement and/or subrogation can be recovered from any source of recovery, such as uninsured motorist, underinsured motorist, medical payments and personal injury protection. You shall do whatever is necessary to secure such rights and shall do nothing to prejudice such rights. You agree to cooperate with PacifiCare and/or its designee by completing forms and giving information surrounding any accident as is necessary to investigate the incident. Should PacifiCare or its designee provide benefits subject to subrogation or reimbursement, PacifiCare or its designee shall be granted a lien and/or an assignment on the proceeds of any settlement, judgment or other payment received by your or your dependents. You hereby consent to the lien and/or assignment and agree to take whatever steps are necessary to assist PacifiCare or its designee to secure the lien. You will authorize and direct your attorney, personal representative or insurance company to directly reimburse PacifiCare or its designee to the extent of the benefits paid by PacifiCare or its designee. You shall not incur any expenses on behalf of PacifiCare s or its desingee s pursuit of its rights. Specifically, neither court costs nor attorneys fees may be deducted from PacifiCare s or its designee s recovery 22

23 without the prior expressed written consent of PacifiCare or its designee. This right shall not be defeated by any Fund Doctrine, Common Fund Doctrine, Attorney s Fund Doctrine. PacifiCare or its designee shall recover the full amount of benefits provided without regard to any claim of fault on the part of any Member, whether under comparative negligence or otherwise. The benefits under PacifiCare are secondary to any coverage under no-fault or similar insurance. Please refer to the Medical and Hospital Group Subscriber Agreement for a complete description of the Third Party Liability provisions. If You re Injured on the Job If you are injured on the job and require medical care, you will need to sign an assignment of benefits. This will allow PacifiCare s contracting providers to bill Workers Compensation directly for their treatment of your injury. Your PacifiCare benefits are not designed to duplicate any benefits you receive under Workers Compensation law. 23

24 Your PacifiCare Plan and Medicare The medical benefits you receive from Medicare are nearly the same as your PacifiCare medical benefits. When Medicare benefits are primary, they will take the place of the PacifiCare plan benefits. PacifiCare will pay for approved benefits less the amount which is paid or the rate that Medicare allows as payment. Medicare benefits generally start at age 65. But Medicare benefits may begin before age 65 for people unable to work due to severe disability. Even the very young are covered in some circumstances. There are also special issues for people age 65 to 69 who are still working. If you have questions about Medicare, contact your local Social Security office. How to Voice a Complaint or Request an Appeal We want you not only to be healthy, but also to be happy with your health plan. So we work hard to give you every opportunity to have any problems or concerns you have with your health care handled in a way that is fast, fair and friendly. If you have a question, comment or concern about your medical care, talk to your physician or your medical group. If you have a question about your benefits, call Customer Service at (800) COMPLAINT RESOLUTION PROCEDURES All initial complaints, except those involving a denial of covered services, should be directed to the PacifiCare Customer Service Center either by telephone at (800) or in writing to PacifiCare, P.O. Box San Antonio, Texas Members wishing to file an appeal of a denied payment or service should contact the PacifiCare of Oklahoma Appeals Department at (918) or (405) , or submit the request in writing to PacifiCare of Oklahoma, Attn: Appeals Department, 7666 E. 61 st Street, Tulsa, Oklahoma The Customer Service Associate shall attempt to resolve the complaint within three calendar days of receipt. If the Customer Service Associate is unable to resolve the issue within the three calendar days, the case will be assigned to the Member Response Team who will investigate, correspond with you, and attempt to bring resolution of the complaint within a thirty day time frame or advise you of your right to request a formal appeal. Complaints concerning service during emergencies or denial of continued stays for hospitalization will be resolved within one business day. All complaints involving a denial will be forwarded to the PacifiCare of Oklahoma Appeals Department. The Appeals Specialists will send you an acknowledgement letter within five business days of receipt of your request for reconsideration. Included with the acknowledgement letter will be a Complaint form (if the initial complaint was not in writing), and a Release of Medical Information form for your completion, signature and return. Upon receipt, the Appeals Specialist will gather and prepare all information for review by your primary medical group and the Plan Medical Director. You will receive written notification of the initial determination within 30 calendar days of receipt of your request. The response letter must include the reason for PacifiCare's determination. If the determination is adverse the response letter must include the clinical basis on which the decision was reached and provide you information regarding your options through the internal appeals process. The next level available to you through the internal appeals 24

25 process would be a Member Satisfaction Hearing or you may appeal through an external review process. 25

26 MEMBER SATISFACTION HEARING You must submit your request for a Member Satisfaction Hearing within seven days of receipt of the initial determination letter submitted by the Appeals Specialist. You may submit your request either orally or in written form. The hearing will be scheduled within thirty days f receipt of your request. The Member Satisfaction Hearing allows you the opportunity to appear in person and present your request/complaint before a committee comprised of a physician, a Plan consumer, and a Plan employee. All are volunteers and will have had no previous involvement in your case. A representative from your Medical Group will also be invited to attend the hearing, but will not have a voice in the decision reached at the hearing. Five working days prior to the hearing, the Appeals Specialist will provide you or your representative the documentation to be presented at the hearing and to the participating committee members. You will receive written notification of the committee's decision within five working days of the hearing. This notification must include specific reasons for the committee's determination. The decision reached at this hearing is binding on PacifiCare and the medical group, but not on you, the member. If the committee's decision is adverse, the written notification shall also include the next step available to you through the internal appeals process or your right to appeal through the external review process. At your request, PacifiCare shall provide, in lieu of the appeals panel, a review by a physician or provider of the same or similar specialty as typically manages the condition, procedure or treatment being appealed. The physician or provider reviewing the appeal may interview you or your designated representative and shall render a decision on the appeal. PacifiCare s written response regarding the appeal must include a statement of the specific medical determination, clinical basis and contractual criteria and the toll-free number and address of the Oklahoma State Department of Health. If the appeal is for an ongoing emergency or denial of continued stays for hospitalization, the decision may be communicated orally if followed by the written determination within three business days. EXTERNAL REVIEW If you meet the following criteria you are given the opportunity to select External Review. You must have received an initial denial based on lack of medical appropriateness, medical effectiveness or medical necessity (as defined in this Member Handbook) for a service or procedure from a Contracting Medical Group. The usual, customary and reasonable charge or allowable charge for the denied treatment or service must exceed five hundred dollars ($500.00). Lastly, you must have appealed the denial to the Reconsideration level, had the denial upheld by PacifiCare and agreed to the terms and conditions of external review. External Review is offered either before or after your Member Satisfaction Hearing, but can be selected only once. If your request for External Review is accepted by the Independent Review Organization (IRO), an IRO certified by the Oklahoma State Department of Health will review your appeal. You will have the opportunity to submit information you believe is relevant to your appeal. The IRO will provide you and PacifiCare with a written decision within thirty (30) days of accepting the appeal and receiving all required documentation. 26

27 BINDING ARBITRATION If you are not satisfied with the outcome of the Member Satisfaction Hearing or External Review, you may elect the final level in the PacifiCare complaint/appeals process, which is Binding Arbitration. Binding Arbitration may be requested by submitting a written letter of request within 60 days of the date of the Member Satisfaction Hearing letter of denial, to the Appeals Specialist. The Appeals Specialist will notify the American Arbitration Association (AAA) of the request. Notification of the date, time and location of the arbitration hearing will be coordinated by the AAA. Advance Directives All adult individuals in hospitals, nursing homes, and other health care settings have certain rights. You have the right to confidentiality of your personal medical records and to know what treatment you will receive. The following information can help you make decisions in advance of treatment. It s your right to make decisions about medical treatment. ADVANCE DIRECTIVES You have the right to complete a form, known as an advance directive. The form says in advance what kind of treatment you want or do not want under special, serious medical conditions conditions that would prevent you from telling your doctor how you want to be treated. For example, if you were taken to a hospital in a coma, would you want the hospital s medical staff to know your specific wishes about decisions affecting your treatment? The following answers some questions related to a federal law in effect as of December 1, 1991, that requires most hospitals, nursing facilities, hospice, home health care programs and health maintenance organizations (HMOs) to give you information about advance directives and your legal choices in making decisions about medical care. The law is intended to increase your control over medical treatment decisions. Because this is an important matter, however, you may wish to talk with family, close friends and your doctor before deciding whether you want an advance directive. Finally, it is important to remember that state laws differ about the legal choices available to individuals for treatment options that will be honored by hospitals and other health care providers and organizations. These health care professionals should have information for you on Oklahoma s advance directive law. WHAT IS AN ADVANCE DIRECTIVE? An advance directive is generally a written statement, which you complete in advance of serious illness, communicating how you want medical decisions made. The three most common forms of an advance directive are: living will (directive to physicians) appointment of a health care proxy Oklahoma do-not-resuscitate order An advance directive allows you to state your choices for health care or to name someone to make those choices for you, if you become unable to make decisions about your medical treatment. In short, an advance directive can enable you to make decisions about your future medical treatment. 27

28 You can say yes to treatment you want, or say no to treatment you don t want. WHAT IS A LIVING WILL? A living will (or directive to physicians) generally states the kind of medical care you want (or do not want) if you become unable to make your own decision. It is called a living will because it takes effect while you are still living. The instructions in your living will are to be followed if you have a terminal condition. Under Oklahoma law, a terminal condition is defined as an incurable and irreversible condition that will result in death within six months. Until two doctors state that you have a terminal condition, your doctors and hospital workers have no legal authority to follow your documented wishes. You may wish to speak to an attorney or your physician to be sure you complete the living will in a way that your wishes will be understood and followed. WHAT IS A HEALTH CARE PROXY? A health care proxy is someone authorized to make decisions for you, should you be unable to make decisions for yourself. The designated proxy must be an individual eighteen (18) years or older. While a proxy is authorized to make medical treatment decisions regarding life-sustaining treatment, the proxy must follow your instructions as outlined in the advance directive. If you become unable to make decisions regarding your medical treatment and have not executed an advance directive indicating your wishes, a guardian may be appointed through the court system to make decisions for you. The court must then approve a guardian s decision to withhold treatment. In some states, laws may make it better to have either a living will or a health care proxy. Oklahoma recognizes the right of the individual to execute a living will, appoint a health care proxy or do both in a single document. WHAT IS AN OKLAHOMA DO-NOT-RESUSCITATE (DNR) ORDER? A DNR order is a request by you that in the case of cardiac or respiratory arrest, you do not want your health care providers to try to revive you. This means that if your heart stops beating or you stop breathing, you would prefer not to have cardiopulmonary resuscitation (CPR). A DNR order is limited to only these two situations, and in that respect is much more limited than the living will, which encompasses all terminal conditions. DO I HAVE TO WRITE AN ADVANCE DIRECTIVE UNDER THE LAW? No. It is entirely your choice. CAN I CHANGE MY MIND AFTER I WRITE A LIVING WILL, DNR ORDER OR APPOINT A HEALTH CARE PROXY? Yes. You may change or cancel these documents at any time in accordance with Oklahoma law. Any change or cancellation should be written, signed and dated in accordance with Oklahoma law, and copies should be given to your family doctor, or to others to whom you may have given copies of the original. If you wish to cancel an advance directive while you are in the hospital, you should notify your doctor, your family, and others who may need to know. Even without a change in writing, your wishes stated in person directly to your doctor generally carry more weight than a living will or appointment of a health care proxy, as long as you can decide for yourself and can communicate your wishes. But be sure to state your wishes clearly, and be sure that they are understood. 28

29 WHAT IF I FILL OUT AN ADVANCE DIRECTIVE IN ONE STATE AND AM HOSPITALIZED IN A DIFFERENT STATE? An advance directive executed in another state will be considered valid in Oklahoma if the directive does not exceed the authorization set forth in Oklahoma law. If you spend a great deal of time in more than one state, you may wish to consider having your advance directive meet the laws of all frequently visited states, as much as possible. WHAT SHOULD I DO WITH MY ADVANCE DIRECTIVE IF I CHOOSE TO HAVE ONE? Make sure that someone, such as your attorney or a family member, knows that you have an advance directive and knows where it is located. You might also consider the following: If you have appointed a health care proxy, give a copy of the original to your agent or proxy. Ask your physician to make your advance directive part of your permanent medical record. Keep a second copy of your advance directive in a safe place where it can be easily found, if it is needed. Keep a small card in your purse or wallet, which states that you have an advance directive, where it is located and who your agent or proxy is, if you have named one. Under the law, when you enter a Medicare or Medicaid hospital or nursing facility, receive home health or hospice care from a Medicare or Medicaid provider, or enroll in a Medicare or Medicaid certified HMO, you should be asked whether you have an advance directive. Should you choose to complete an advance directive, it is your responsibility to provide a copy to your physician and to bring a copy with you when you check into a hospital or other health facility so that it can be kept with your medical records. HOW CAN I GET MORE INFORMATION ABOUT ADVANCE DIRECTIVES? The Oklahoma State Department of Human Services will provide telephonic assistance in completing the Advance Directive form. They can be reached at (405) Additionally, you may call PacifiCare Customer Service from 8:00 a.m. to 6:30 p.m. weekdays at (800) Technology Assessment Committee PacifiCare has a Technology Assessment and Guideline review process which is designed to research and review requests for coverage of newly available special devices, procedures or treatments that are not considered established benefits but for which Members may be eligible. PacifiCare ensures that all requests are reviewed by two external consultants. Recommendations from the consultant/reviewer are sent to the Technology Assessment and Guideline Committee for discussion. On a routine basis, the Committee will review all requests and issue a formal decision. Approval must be provided by any appropriate regulatory agency, such as the Oklahoma State Department of Health before a final decision can be issued. To promote the health and safety of a Member, PacifiCare requires scientific evidence to ensure the effect and safety of the new technology to the Member s health. The new technology must improve the net health outcome of the Member, be as beneficial as any established alternative, be attainable outside the investigation setting and significantly improve the quality of life of the Member. 29

30 Additionally, the new technology must clearly demonstrate safe care to the Member. 30

31 Commonly Asked Questions and Answers Q My coverage has started but I haven t received my Member ID card yet. What do I do if I need to visit my physician? And, what if I need to get a prescription filled? A Call your Primary Care Physician and schedule an appointment. When you go in for your appointment, let your doctor know you are a PacifiCare Member but haven t received your ID card yet. You will be asked to sign an eligibility guarantee form at that time. If you need to have a prescription filled, go to a contracting pharmacy listed in your Provider Directory. You can pay for the prescription at that time and then be reimbursed by PacifiCare. Or call the PacifiCare Customer Service Center. They can arrange for you to receive a prescription without an ID card. Q Can I change to another Primary Care Physician? A Yes. You may change physicians by contacting the PacifiCare Customer Service Center by the 20 th day of the month to become effective the following month. The change will be effective the first of the month following the required notification. Customer Service can also help you change to another medical group. Q What if I want to see a specialist? A See your Primary Care Physician first for all your medical care. He/she will decide if you need to see a specialist. Please be aware that each medical group contracts with a different network of specialists. Q Do I have to receive all of my medical care from the Primary Care Physician I choose? A Yes. The physician you selected is responsible for coordinating all of your medical care, including visits to specialists. However, this does not prohibit you from seeing physicians outside of the PacifiCare network at your own expense. Q How does PacifiCare decide whether to include a new procedure, device or drug as a covered benefit? A PacifiCare regularly reviews new procedures, devices and drugs to determine whether or not they are safe and effective for Members. The Technology Assessment and Guideline Committee, consisting of staff experts, Primary Care Physicians, pharmacists and specialists, conduct careful reviews of case studies, clinical literature, and Medicare and Federal Drug Administration decisions. If the proved benefits of a new treatment outweigh the risks, the new treatment is added to the Member s benefits and coverage is adjusted accordingly. Q What if I quit or lose my job can I continue my PacifiCare coverage? A Yes. In most cases you can continue your coverage through a federal law called COBRA. Contact your employer for more information about COBRA. PacifiCare also offers an individual conversion plan in certain cases. If eligible for this plan, you must contact the PacifiCare Customer Service Center within 30 days from your last date of coverage through your employer. Q What should I do if I receive a bill from a medical group, hospital or physician? A If you ever receive a bill for services covered under your health plan, send it to the PacifiCare Claims Department immediately. If the services you received were covered 31

32 and authorized by your Primary Care Physician, they will be processed for payment. Q I have children who go to college out-of-state. Are they covered? A Your dependents are covered out-of-area for urgent and emergency care only, just as you would be covered while traveling. Any routine or follow-up care will be managed by your Primary Care Physician. Q Can I see a gynecologist for my annual pap and pelvic exams? A Female Members may self-refer to an OB/GYN contracted with their medical group one time each year for a pap smear and pelvic and breast exams. Members are covered also for a mammogram if it is authorized by the medical group. Also, the test must be done in a facility contracted with the medical group. Contact your medical group for a list of contracting OB/GYNs. Q Does PacifiCare cover periodic health evaluations? A Yes. Our goal is not only for you to get well when you are sick, but also for you to stay healthy. Preventive health evaluations such as well baby care, eye exams and other routine services recommended by your Primary Care Physician are covered. Because periodic health evaluations are routine, non-urgent visits, please schedule these well in advance. 32

33 Definitions Copayments are fees paid by a Member to a health care provider. Copayments are usually due when service is delivered. These fees are in addition to the premiums paid by the employer group. Copayments may be a specific dollar amount, a percentage of negotiated fees or total billed charges (when there is no agreement between PacifiCare, the medical group and/or the provider). Dependent is any spouse or unmarried child (including stepchildren and legally adopted children) of the subscriber. Dependents are covered by PacifiCare when they meet eligibility and premium requirements.emergency care is based on your presenting symptoms arising from any injury, illness or condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable and prudent layperson could expect the absence of medical attention to result in 1) serious jeopardy to the patient s health (or in the case of a pregnant woman, serious jeopardy to the health of the fetus); 2) serious impairment to bodily function; or 3) serious dysfunction of any bodily organ or part. Enrollment is the event when a person becomes a health plan Member. A Member is enrolled when PacifiCare accepts the enrollment form submitted by the subscriber. PacifiCare and the employer group must abide by the Medical and Hospital Group Subscriber Agreement and the employer group must pay premiums on time. Experimental or Investigational are those procedures and/or items determined by PacifiCare not to be generally accepted by the medical community. Extended care facility or skilled nursing facility is a skilled nursing facility or skilled nursing unit of a hospital. PacifiCare contracts with extended care facilities that are certified under Titles XVIII and XIX of the Social Security Act. External Review is an appeal process by which a Member, if eligible, may have a denied claim reviewed by an Independent Review Organization. Health plan is a company providing health care benefits to its Members. The PacifiCare health plan is described in the PacifiCare Medical and Hospital Group Subscriber Agreement, including cover sheet and attachments. Health plan premiums are the set amount an employer pays each month to the health plan for delivery of health care benefits for its Members. Hospital is an acute care medical facility. PacifiCare contracts with hospitals licensed by the State of Oklahoma. Each contracting medical group designates a hospital for delivery of hospital services to Members. Hospital services are medically necessary services provided by a hospital. The services may be provided on an inpatient or outpatient basis. They are prescribed, directed or authorized by a Member s Primary Care Physician. 33

34 Medical and Hospital Subscriber Agreement is the contract between PacifiCare and your Employer. This contract will prevail over any conflicting information. Medical group is any group of licensed doctors of medicine or osteopathy. A contracting medical group is a medical group that has entered into a written agreement with PacifiCare to provide medical services to PacifiCare members. Medical Necessity. An intervention will be covered under the PacifiCare Health Plan if it is an otherwise covered category of service, not specifically excluded, and medically necessary. An intervention may be medically indicated yet not be a covered benefit or meet the definition of medical necessity. An intervention is medically necessary if, as recommended by the treating physician and determined by the medical director of PacifiCare or the Contracting Medical Group, it is (all of the following): (a) (b) (c) (d) A health intervention for the purpose of treating a medical condition; The most appropriate supply or level of service, considering potential benefits and harms to the Member; Known to be effective in treating the medical condition. For existing interventions, effectiveness is determined first by scientific evidence, then by professional standards, then by expert opinion. For new interventions, effectiveness is determined by scientific evidence; and If more than one health intervention meets the requirements of (a) through (c) above, furnished in the most cost-effective manner which may be provided safely and effectively to the Member. In applying the above definition of medical necessity, the following terms shall have the following meanings: (i) A health intervention is an item or service delivered or undertaken primarily to treat (that is, prevent, diagnose, detect, treat, or palliate) a medical condition or to maintain or restore functional ability. A medical condition is a disease, illness, injury, genetic or congenital defect, pregnancy, or a biological condition that lies outside the range of normal, age-appropriate human variation. A health intervention is defined by the intervention itself, the medical condition and the patient indications for which it is being applied. (ii) Effective means that the intervention can reasonably be expected to produce the intended results and to have expected benefits that outweigh potential harmful effects. (iii) Scientific evidence consists primarily of controlled clinical trials that either directly or indirectly demonstrate the effect of the intervention on health outcomes. If controlled clinical trials are not available, observational 34

35 studies that suggest a causal relationship between the intervention and health outcomes can be used. Such studies do not by themselves demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything that could be explained either by the natural history of the medical condition or potential experimental biases. For existing interventions, the scientific evidence should be considered first and, to the greatest extent possible, should be the basis for determinations of medical necessity. If no scientific evidence is available, professional standards of care should be considered. If professional standards of care do not exist, or are outdated or contradictory, decisions about existing interventions should be based on expert opinion. Giving priority to scientific evidence does not mean that coverage of existing interventions should be denied in the absence of conclusive scientific evidence. Existing interventions can meet the definition of medical necessity in the absence of scientific evidence if there is a strong conviction of effectiveness and benefit expressed through up-to-date and consistent professional standards of care or, in the absence of such standards, convincing expert opinion. (iv) A new intervention is one which is not yet in widespread use for the medical condition and patient indications being considered. New interventions for which clinical trials have not been conducted because of epidemiological reasons (i.e., rate or new diseases or orphan populations) shall be evaluated on the basis of professional standards of care. If professional standards of care do not exist, or are outdated or contradictory, decisions about such new interventions should be based on convincing expert opinion. (v) An intervention is considered cost effective if the benefits and harms relative to costs represent an economically efficient use of resources for patients with this condition. Medical services are the medically necessary professional services delivered by a physician, surgeon or paramedical personnel. Medical services must be directed or authorized by a Member s Primary Care Physician or specialty physician. Member is any subscriber or dependent. Patient Care Committee is a group of physicians from your medical group organized to promote appropriate and quality health care through prospective, concurrent and/or retrospective review of Member cases. The committee allows discussion of special medical situations with colleagues. These may include consultative review of referrals to specialty physicians, referrals for hospital admissions, review of urgent or elective emergency room care and referrals for specialty services such as diagnostic procedures, outpatient surgeries, lab and X-ray. Prevailing rates are the usual, reasonable and customary fees for a particular health care service in a designated area. Primary Care Physicians are medical doctors and osteopaths licensed to practice medicine or osteopathy in the State of Oklahoma. Contracting Primary Care Physicians are physicians or osteopaths who have written agreements 35

36 with PacifiCare to provide medical services to PacifiCare Members. Or these doctors may have an ownership interest in, be employed by or contract with a contracting medical group. Providers are physician groups, allopathic physicians, osteopathic physicians, chiropractic physicians, podiatrists, optometrists, hospitals, skilled nursing facilities, extended care facilities, home health agencies, alcohol and drug abuse centers, mental health professionals, and any other health facilities or providers. Quality/Health Improvement Programs are programs and services aimed at improving your health through education, focusing on primary and secondary prevention, as well as disease management (e.g., Healthy Pregnancy and StopSmoking programs). Service area is a geographical area, as determined by the Oklahoma State Department of Health, within which PacifiCare arranges for medical and hospital services. Skilled nursing facility see extended care facility. Specialty physicians are physicians, surgeons and osteopaths licensed to practice medicine or osteopathy in the State of Oklahoma. Contracting specialty physicians have written agreements with PacifiCare or a contracting medical group to provide specialty medical services. Subscriber is an individual who has enrolled in the health plan. A subscriber is a person who meets the eligibility requirements of the PacifiCare Medical and Hospital Group Subscriber Agreement and for whom the appropriate health plan premium has been received by PacifiCare. When an employer pays the premium, the subscriber is the employee. 36

37 PacifiCare Member Rights and Responsibilities AS A PACIFICARE MEMBER, YOU HAVE THE RIGHT TO: Timely, Quality Care! Choice of quality contracted physicians, health care professionals and providers. (Note: selection choice may be limited by the contracting providers caseload.)! Candid discussion of appropriate or Medically Necessary treatment options for your condition, regardless of cost or benefit coverage.! Timely access to your Primary Care Physician and Referrals to Specialists when Medically Necessary.! Use Emergency Services when you, as a prudent layperson acting reasonably, believe that an Emergency Medical Condition exists.! Actively participate in decisions regarding your own health and treatment options.! Receive Urgently Needed Services. Treatment with Dignity and Respect! Be treated with dignity and respect and to have your right to privacy recognized.! Exercise these rights regardless of your race, disability, ethnicity, gender, sexual orientation, creed, age, religion or your national origin, cultural or educational background, or your economic or health status, English proficiency, reading skills, or source of payment for your care. Expect these rights to be upheld by both the Plan and contracted providers.! Confidential treatment of all communications and records pertaining to your health care and the care of other patients. You have the right to access your medical records. The Plan must provide timely access to your medical records or other health and enrollment information that pertains to you. To obtain information regarding how to access your medical records, contact the PacifiCare Customer Service Department. Written permission from you or your authorized medical representative shall be obtained before medical records can be made available to any person (including your employer, if appropriate), who is not directly concerned with your health care or responsible for making payments for the cost of such care. Protection of confidential information covers all PacifiCare internal departments, any contracted entities and research and treatment settings.! Extend your rights to any person who may have legal responsibility to make decisions on your behalf regarding your medical care.! Refuse treatment or leave a medical facility, even against the advice of a physician, provided you accept the responsibility and consequences of the decision.! Complete an Advance Directive, Living Will or other directive to a contracting medical provider.! Receive the full set of PacifiCare s confidentiality policies upon request.! Make recommendations regarding the members rights and responsibilities policies. Health Plan Information! Information about your health plan, covered services, and member rights and responsibilities.! Know the names and qualifications of physicians, health care professionals and contracting providers involved in your medical treatment.! Receive information about an illness, the course of treatment and prospects for recovery in terms you can understand, including how medical treatment decisions are made by the contracting medical group.! Information about our contracted physician payment agreements, as well as explanations for any bills for noncovered services, regardless of payment source.! Information about your medications what they are, how to take them and possible side effects.! Receive as much information about any proposed treatment or procedure as you may need in order to give an informed consent or to refuse a course of treatment. Except in Emergencies, this information shall include a description of the procedure or treatment description, the medically significant risks involved, any alternate course of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment.! Reasonable continuity of care and to know the time and location of an appointment, the name of the physician providing care and to be informed of continuing health care requirements following discharge from inpatient or outpatient facilities.! Be advised if a physician proposes to engage in experimental or investigational procedures affecting your care or treatment. You have the right to refuse to participate in such research projects.! Be informed of continuing health care requirements following discharge from inpatient or outpatient facilities. 37

38 Timely Problem Resolution! Voice complaints and appeals about PacifiCare or the care provided without discrimination and expect problems to be fairly examined and appropriately addressed.! Responsiveness to reasonable requests made for covered services. AS A PACIFICARE MEMBER, YOU HAVE THE RESPONSIBILITY TO:! Provide to the extent possible, physicians, health care professionals and contracting providers the information needed in order to care for you.! Do your part to improve your own health condition by following treatment plans, instructions and care that you have agreed on with your physicians(s).! Participate, to the degree possible, in understanding your behavioral health problems and developing mutually agreed upon treatment goals.! Adhere to behavior that reasonably supports your treatment plan and the recommendation of your primary care physician or other contracting medical provider.! Review information regarding Covered Services, policies and procedures as stated in your Member Handbook.! Accept the financial responsibility associated with services received while under the care of a physician or while a patient at a facility.! Ask questions of your contracting physician or PacifiCare. If you have a suggestion, concern, or a payment issue, we recommend you call our Customer Service Department. 38

39 Notes 39

40 7666 East 61st Street Tulsa, OK Central Park Drive, Suite 350 Oklahoma City, OK PacifiCare Customer Service P.O. Box San Antonio, TX (800) Telephone Device for the Hearing Impaired (TDHI) (800) Internet Address: PCPOST Copyright 2000 by PacifiCare Health Systems, Inc. OKMBR00 40