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Frequently Asked Questions

If you have questions about your medical care, you should speak directly with your physician. If you have general questions about how your health care system works, you might find the following frequently asked questions and answers helpful. Since benefits vary from plan to plan, and in some unique circumstances, other rules may apply, it's important to verify information with your own health plan

Q. How long does it take to process an authorization?

Authorizations are processed as quickly as possible. Requests are processed in order of medical urgency. Urgent requests are processed within 72 working hours. Routine requests are processed within 5 business days. Sometimes requests are pended for further review if the physician has not supplied all supporting information required.

Q. What are the steps to change my Primary Care Physician?

Please contact your health plan directly to change your Primary Care Physician. We would be happy to assist you by answering any questions you might have prior to selecting a physician.

Q. What claims are paid by my medical group?

Your medical group is contracted with each health plan for specific services. In general, your medical group pays physician services.

Q. What is my next step if my authorization has been denied?

You may contact your Primary Care Physician for alternative options. You may also utilize the appeals process outlined in the denial letter by contacting your health plan.

Q. I've seen a specialist and they want to see me for a follow-up and he is asking that my PCP request an authorization but the PCP is asking that the specialist get the authorization. In this situation, who should request the authorization?

Either physician may submit an authorization request. In general, the specialist is in the best position to provide the supporting information necessary for the request.

Q. Do I need a prior authorization for a follow-up visit to a Gynecologist for any abnormal testing?

Follow-up office visits to an OB/GYN do not require prior approval. All medical procedures DO require prior approval. Your participating OB/GYN is familiar with the protocols.

Q. I need a routine eye exam, am I covered?

Medical exams are covered under your health insurance. Routine vision screening exams (for prescription glasses/contact lenses) may be covered under a separate vision policy called a rider. You should contact your health plan directly to review your specific plan/benefits.

Q. Do you have urgent care? Where do I go?

You are always required to contact your Primary Care Physician first. Your physician is required to triage your care and provide access to urgent appointments as necessary. If necessary, your Primary Care Physician will refer you to an urgent care location.

Q. What is the difference between the medical group and the health plan?

The health plan is your "insurance company" for all services covered under your benefits. The health plan subcontracts with the Medical Group to provide a specific sub-set of physician services.

Q. What is my co-pay?

All policy and benefit information is maintained by the health plan. Please review your membership card, your benefits manual and contact your health plan with questions.

Q. I'm currently out of state, which doctors can I see?

Contact your health plan for specific instructions on how to access out-of-area care.

Q. I'm calling to change my name, address, and phone number. What is the process?

Contact your health plan to make these changes. Your health plan maintains all of your membership information.

Q. Can I go to the hospital for diagnostic testing?

Your physician will refer you to the appropriate contracted facility.

Q. Do I need an authorization for ER service? If so, when?

No authorization is required to access services at a hospital Emergency Room. You should call 911 in the case of an emergency. If it is not an emergency, you are encouraged to contact your Primary Care Physician for assistance. At a minimum, you should follow-up with your Primary Care Physician after visiting an Emergency Room.

Q. Who can I call if I need language assistance or translation services?

Call the Member/Customer Service number on your health plan ID card or call us at (858) 824-7000. TTY Users call 711.