If
your PCP feels
you need care from
a specialist, you
will be referred
to one affiliated
with our medical
group. Your
PCP will tell which
specialist to see
and give you a
written referral.
Female patients
do not need a referral
to see an OB/GYN
for routine care,
as long as they
choose one affiliated
with Valley Care
IPA. And sometimes
a referral is not
needed for ongoing
care, based on
your condition
and care needs.
You must use the approved
specialist in order
for your health plan
to cover the services.
The PCP’s office staff will
tell you how to make an appointment, or they may help you do
so.
We base our care referral decisions on nationally recognized
objective standards, criteria and guidelines. As
part of our utilization management program, our Utilization
Management Department needs to evaluate some types
of services before the referral to a specialist will
be approved. We will notify you and your PCP if the
referral is approved.
Our utilization management
program relies on established
utilization review decision-making
standards, criteria
and guidelines that
are based on sound medical
evidence. Our clinical
staff evaluates them
regularly to be certain
that they reflect the
needs of our patients.
We also make sure that
our clinical decision-makers,
doctors, nurses and
other health professionals
consistently apply the
criteria for all patients.
We make these promises
when we make decisions
about our patients'
health care services:
- Only
board certified
doctors and
qualified
health professionals
perform service
reviews and
make utilization
management
decisions
about the
special services
requested
by your doctor.
- We
base service
review decisions
are based
solely on
the appropriateness
of care and
service and
each patient's
own health
plan benefits.
- We
do not give
reward our
review decision-makers
for denials
any kind of
reward to
deny of coverage,
services or
care.
- We
do not offer
our review
decision-makers
any financial
incentives
to limit,
restrict or
discourage
use of health
care services.
- If
we do not
approve a
referral request,
you are entitled
to receive
the services
at your own
expense. Together,
you and your
treating physician
decide whether
you receive
a particular
service or
treatment.
- Once
we authorize
a referral,
treatment
or service,
we will
not change
or reverse
that
decision
after
you receive
the authorized
services.
If you have questions
about a review decision
we have made or wish
information about the
review of your particular
referral request, call
our Managed Care Call
Center. See the
Call
Us For Help
section
below for the Managed
Care Call Center’s
phone number and hours
of operation. |
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