Frequently Asked Questions
- How does my group interact with my insurance company?
- What is the role of my primary care physician?
- My primary care physician has told me I need to see a specialist. What happens now?
- Are there any services that don’t need an authorization?
- Who receives my co-payment?
- What if I receive a bill?
- We go on vacation often. Will I be covered if I should become ill?
- How do I file a complaint/grievance or an appeal?
How does my group interact with my insurance company?
We represent your physicians. Your health plan requires you to choose a primary care physician. You’ve chosen a primary care physician with us. Your primary care physician and your group will be coordinating all of your care, using our specialty and hospital network. Your insurance company determines your benefits (e.g., your co-payment amount when you see a physician or go to an emergency room). If you have your insurance through your employer, your employer and insurance company work together to determine what your monthly premium will be. The premium is paid directly to your insurance company by you or your employer.
What is the role of my primary care physician?
Your primary care physician is always the first person you should contact when you have a medical condition. If you think you have the flu, call your primary care physician. If you have knee pain, call your primary care physician. Your primary care physician will most likely want to see you before determining if you should be referred to a specialist for a specific condition. The only exception is if you are experiencing a life threatening emergency (e.g., a sudden onset of chest pain). If this should occur, you should always call 911 or go to the nearest emergency room. To see a list of our preferred hospitals, click here, and urgent care centers, click here.
My primary care physician has told me that I need to see a specialist. What happens now?
Your primary care physician will submit an authorization request to us. We will determine which of our specialists is the most appropriate. You will then receive an authorization in the mail. Remember, for a claim to be paid, you must have an authorization for the service.
Are there any services that don’t need an authorization?
We do offer services, called self-referral, that do not need an authorization as long as you self-refer to a participating specialist. These services include Well Woman Exams, OB care, Well Child visits, and first visits. We also offer several direct referral services. This means that your primary care physician is able to send you directly to a contracted specialist. Call our Customer Service Department at (818) 654-3400 for a list of the services available to you.
Who receives my co-payment?
All co-payments are made to the provider at the time services are received. Remember, your insurance company determines your co-payment amount. This is not established by your physician or medical group.
What if I receive a bill?
If you have received an authorization for services or if you have self-referred for one of the services indicated above, you should not receive a bill. There are times when labs or radiology departments may send their patients a bill because they did not get complete information at the time of service. Whenever you receive a bill or statement, please call our Customer Service Department.
We go on vacation often. Will I be covered if I should become ill?
If you become ill on vacation, you should see a physician or go to an urgent care location. The majority of the time, these visits will be covered; however, it’s important for you to know that you may have to pay for the services. Most providers in another area will not bill your insurance company. This is especially true for out-of-state providers and cruise ships. You need to contact your insurance company and ask for a claim form. Once this is received, mail your receipts to your insurance company for review. This also includes receipts for prescriptions that you may have had filled. Remember, over-the-counter medications are not reimbursable.
If you experience a life-threatening emergency while traveling, it is very important that you go to the nearest emergency room. Most emergency rooms will contact your insurance company to advise of your condition, discuss your treatment plan, and also determine where bills should be sent. Upon your return home, be sure to contact your primary care physician to advise him/her of your illness while away from home. It’s important that your medical records are updated. If you need to receive continued care for the condition, your primary care physician will be the one coordinating any care you receive.
How do I file a complaint/grievance or an appeal?
We do want to assist each and every member in every way possible. If you have any questions and/or concerns, do not hesitate to contact our Customer Service Department at (818) 654-3400 anytime between 8:00 a.m. and 5:00 p.m. Monday through Friday.
Appeals:
If you are not satisfied about a decision regarding the denial of services or payment, please refer to your Evidence of Coverage (EOC) for detailed instructions about how to file an appeal, or you can call your health plan directly.
Grievances:
If you are dissatisfied with us and/or any of our providers, including quality of care concerns, please contact your health plan and file a formal grievance.
We strive for excellence in healthcare and will work closely with your health plan to ensure the highest quality of care.
If you have any further questions, you may contact our Customer Service Department at (818) 654-3471.
