Healthy Kids - About Getting Care
PHC MEMBER SERVICES DEPARTMENT
PHC has a Member Services Department that is available Monday - Friday, 8:00 am - 5:00 pm. You can call us at (707) 863-4120 or (800) 863-4155. The Member Services Representative are there to answer your questions about PHC and help you with any problems you may have related to your medical care.
You should call the Member Services Department if you:
- Want to transfer to a new primary care provider.
- Are getting a bill for medical care.
- Need a new PHC ID card
- Would like to file an appeal or complaint about PHC, your medical care, or your medical provider.
- Have any questions about PHC or the services PHC provides.
- Have a problem getting a medical appointment.
- Have a problem getting a prescription filled.
Multi-lingual services and services for hearing, speech and visually impaired members are available through the PHC Member Services Department. For more information about these services, call our Member Services Department or refer to the appropriately titled sections of this website for additional information.
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CHOOSING YOUR PRIMARY CARE PROVIDER
If you would like help picking a primary care provider, you can call the PHC Member Services Department at (707) 863-4120 or (800) 863-4155. If you would like a list of providers, you can call our Member Services Department or access the list through this web site. To view PHCs list of participating providers, you must select the prompt titled "Provider" from the menu bar that runs across the top of this screen. Next, you will scroll down to the menu selection titled "Provider Directory" and then select your county of residence.
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MAKING A DOCTORS APPOINTMENT
New PHC members should make an appointment with their primary care provider for a health check-up right away. This is a great way to get to know your doctor and make sure you are in good health. If you don't know who your doctor is, call our Members Services Department at (707) 863-4120 or (800) 863-4155.
Always carry your PHC ID card. Be sure to show your health insurance card when you receive medical care.
Sometimes doctor's offices get backed up and you may have to wait longer then you would like for an appointment. So if you're not feeling well, don't wait until the last minute to make an appointment to see your doctor.
If you are not able to keep your doctors' appointment, please call to cancel your appointment as soon as you can. Try to cancel your appointment at least 24 hours in advance.
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YOUR HOSPITAL
PHC members have been assigned to a primary care provider. Did you know that PHC members have also been assigned to a hospital? If you don't know which hospital you have been assigned to, call our Members Services Department at (707) 863-4120 or (800) 863-4155..
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MEDICAL CARE AT NIGHT AND ON THE WEEKENDS
Most doctor's offices and clinics are closed at night and on the weekends. So, what should you do if you need health care after-hours?
- Call your Primary Care Provider's office. Each office has after-hours services.
- Or, call the PHC Advice Nurse.
The Advice Nurse is available to you 24 hours a day, 7 days a week. The Advice Nurse phone number is (866) 778-8873. You can use this free service if you're not sure if you should go to the emergency room or if you have a medical question that can't wait until the next day. If you have a life threatening emergency, you should go to the closest emergency room or call 911.
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LINGUISTIC SERVICES
To choose a doctor or medical group who speaks your language, refer to the PHC Provider Directory for a list of languages spoken at each provider office. If you need interpreter services when accessing medical care, you should call your doctor or the PHC Member Services Department to request this service. Interpreting services are available to you at no charge when accessing health care. You can request face-to-face or telephone interpreter services. Face-to-face interpreting services need to be approved by PHC in advance. You do not need to use friends or family members as interpreters, unless you choose to. PHC also provides all written materials to our members in English and Spanish.
You have the right to file a complaint or an appeal if you feel your linguistic needs have not been met. For more information about filing a complaint or an appeal, call our Member Services Department at (707) 863-4120 or (800) 863-4155. You can also refer to the section of this web site titled "How to File a Complaint or Appeal".
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SERVICES FOR THE VISUALLY IMPAIRED
To receive an audio version of your PHC member materials, contact the PHC Member Services Department at (707) 863-4120 or (800) 863-4155. Braille versions are available to members who are visually and hearing impaired.
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SERVICES FOR THE HEARING AND SPEECH IMPAIRED
You can contact the PHC Member Services Department through the California Relay Service by calling (800) 735-2929, or call 711.
For information about sign language interpreting, contact our Member Services Department at (707) 863-4120 or (800) 863-4155.
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PHARMACY SERVICES
If you have a prescription that needs to be filled, you should take it to one of the pharmacies on the pharmacy listed in this web site. If you are going to need to get a prescription filled while out of your county of residence, you should call the PHC Member Services Department for information about available pharmacies out of your county of residence.
There is a $5.00 co-payment per prescription. Generic Drugs are used unless there is not generic equivalent for a brand name drug, of unless there is a medical reason for you to have to take a brand name drug instead of the generic equivalent.
PHC keeps a list of drugs called a "Drug Formulary." PHC's Pharmacy and Therapeutics Committee meets quarterly to review and revise the formulary. Drugs are evaluated and selected for the formulary based on tier safety, quality, effectiveness and affordability. In some cases your doctor may choose to prescribe a drug that is not on the formulary. In order for this drug to be covered, your doctor must obtain approval form PHC before your prescription is filled.
If you would like a copy of the PHC Drug Formulary, you can contact the PHC Member Service Department. The formulary is also available on the web site.
Click here for the PHC Drug Formulary
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MAIL ORDER PHARMACY SERVICES
PHC has contracted with Walgreen's Mail Order Service Pharmacy to provide a mail order service for maintenance medications and for PHC members. This is a great service that is FREE and will save you many unnecessary trips to the pharmacy.
For more information about this free service, please call our Member Services Department at 707-863-4120 or 800-863-4155.
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CONTINUATION OF CARE
If the contract between PHC and your provider is terminated, you will get a notice from us in the mail at least sixty (60) days before the termination date or as soon as possible after PHC is notified. You may be able to continue receiving services from a terminated provider if the provider has been providing care to you for one of the conditions listed below at the time the contract between the provider and the plan is terminated.
If you are a new PHC member and were seeing a provider who is not contracted with PHC for any of the conditions listed below at the time you became a member, you may be able to continue seeing this
provider.
If the contract between PHC and a hospital is terminated, and you live within fifteen (15) miles of the
hospital, you will get a notice in the mail from us at least sixty (60) days before the termination date or
as soon as possible after PHC is notified. You may be able to continue receiving services at a terminating hospital if you will be in the hospital at the time or after the contract between the plan and
the hospital terminates and will be receiving services for one of the conditions listed below.
If you are a new PHC member and were in or were scheduled to go to a hospital not contracted with
PHC at the time you became a member, you may be able to continue to go to this hospital if you are
receiving services for one of the conditions listed below.
The conditions that qualify for continuation of care are:
- an acute condition
- a serious chronic condition
- pregnancy
- a terminal illness
- a pending surgery or procedure that was scheduled to occur within 180 days of your effective date of coverage with PHC or from the date a provider is being terminated from the plan's network
- a child age 0-36 months that wishes to keep his/her existing provider for up to 12 months
whether in a course of active treatment or not In order for you to continue to receive care from the provider or hospital, the provider or hospital must be willing and must agree to the terms, conditions and payment rates as set by PHC and followed by other PHC network providers and hospitals.
If you are interested in requesting continuation of care or would like to request a copy of the plan's
continuation of care policy, please call Member Services at 707-863-4120 or 800-863-4155.
PRIOR AUTHORIZATION (an OK by PHC)
PHC must approve some medical services, medical equipment, medical supplies and/or medications
before you get them. Prior authorization means that both your doctor and PHC agree that the services
you will get are medically necessary.
If you need something that requires prior authorization, the health care provider will send us a Treatment
Authorization Request form (or "TAR" for short). Your provider knows which services require a TAR.
They include:
- Non-emergency hospital care
- Some types of medical supplies and durable medical equipment such as wheelchairs
- Some outpatient diagnostic tests such as MRIs
- Some medications
When we get a TAR, it is reviewed by our medical staff (doctors, nurses and pharmacy staff). They
review each case to make sure you are getting the best and most appropriate treatment for your medical
condition.
We approve most TARs, but sometimes a TAR is deferred. This means that we need to ask the provider
for more information or ask that he/she try another treatment first. We will let your doctor know if a
TAR was approved, or if we need more information. Please check with your doctor if you want to know
if a TAR has been approved or not. We respond to all TARs within five (5) business days from the time
we receive them. If a treatment is urgent, we respond within one (1) business day.
After a TAR has been approved, the provider can give you the service or medication. In the few cases
where a TAR is not approved, both you and the provider will get a letter from us within 1-2 business days. This is called a denial. The letter will tell you and the provider that the TAR was denied and why.
It will also tell you and the provider about your right to appeal the denial and gives you information on
how to do that.
You can call our Member Services Department if you would like more information on how we make
these decisions.
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