Medi-Cal - 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 Representatives 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

Partnership HealthPlan of California (PHC) sends all new members a list of primary care physicians (PCP) that participate in our health plan. PHC members are asked to review this list and then notify PHC of the PCP they have selected.

If you would like a list of participating physicians, you can call the PHC Member Services Department at (707) 863-4120 or (800) 863-4155. You can also access the list through this web site. To view PHCs list of participating physicians, 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, your Medi-Cal card and any other health insurance cards you have. Be sure to show all of your health insurance cards 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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HOW LONG SHOULD I WAIT FOR A DOCTOR'S APPOINTMENT?

Regular non-emergency visits:

In need of preventive care such as a physical or annual check up?

• Babies 0 to 24 months: 14 days from when you call for an appointment.
• Children over 24 months and adults: Up to 6 weeks from when you called for an appointment.

Newborn babies just released from the hospital:

Newborn babies released from the hospital less than 48 hours after birth are to be seen within 2 days from when they leave the hospital.

Newborn babies released from the hospital 48 hours or more after birth are to be seen within 2 weeks from the day they leave the hospital

Wanting to be seen for a minor medical need such as a cold?

• 2 weeks from when you called to schedule an appointment.

Urgent or Emergency Visits:

Need to be seen due to an urgent medical need due to a high fever?

• Scheduled no more than 24 hours after you have contacted your doctor's office.

Need to be seen due to an emergency situation?

• You should receive an immediate response or your doctor's office should send you to the emergency room

At the doctor's office:

How long should I wait in the doctor's office if I have a scheduled appointment?

• The time a doctor spends with a patient is uncertain and depends on the patient's medical condition. You may have to wait in the doctor's office up to an hour after your scheduled appointment time.

On the phone or waiting for a call back:

Calling your doctor's office to schedule an appointment?

• You should not be on hold for more than five minutes.
• For non-urgent problems, you should get a call back within eight hours or the following business day.
• For urgent issues, you should get a call back within one hour.

If you have any problems with scheduling appointments or your doctor's office is not meeting these time frames, please call the PHC's Member Services Department for help. We are available Monday through Friday from 8 a.m. to 5 p.m. at (707) 863-4120 or (800) 863-4155.

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YOUR HOSPITAL

Most PHC members have been assigned to a primary care provider. Did you know that most 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 from 5:00 pm - 8: 00 am, Monday - Friday and 24 hours a day on the weekends and holidays. Phone: (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.

PHC members assigned to the medical providers listed below should use the after hours services available through their assigned medical providers.

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GETTING YOUR PRESCRIPTION FILLED

You should never have to pay for a prescription that is covered and medically necessary. If you are having a problem getting a prescription or you had to pay for a prescription, you should call our Member Services Department right away. Our phone number is (707) 863-4120 or (800) 863-4155.

PHC only covers brand name drugs when a generic equivalent drug is not available. However, if there is a medical reason why a generic drug may not be used, a request for authorization must be submitted to PHC indicating the medical reason.

Below are some tips on getting prescriptions filled more quickly and easily:

• Always present all of your health insurance cards, including your PHC ID card and your Medi-Cal card.
• Find a pharmacy that you like and when possible get your prescriptions filled there.
• Listen and follow the pharmacist's instructions about how often you should take your medicine.
• Call ahead to your pharmacy when you need a refill. Don't wait until you run out of medicine. You should call when 75% of your prescription is gone.

If you have a problem getting your prescription filled, you should:

• Ask to speak to the head pharmacist or pharmacy manager.
• Call the PHC Members Services Department at (707) 863-4120 or (800) 863-4155.

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SPECIALTY CARE

A Specialist is a medical doctor who has had extra education in a special area of medicine. Your primary care provider (PCP) will refer you to a specialist as needed. A referral to a specialist must be approved by your PCP, but does not need to be approved by PHC. Your PCP will notify PHC of the specialist referral by using a form called Referral Authorization Form (RAF). If you have any questions about the referral process, you can call our Member Services Department at (707) 863-4120 or (800) 863-4155.

There are some services that do not require a referral from your primary care doctor. Those services are:

Family Planning Services - You do not need a referral for family planning services. You can go to any Medi-Cal provider that is willing to provide these services. Examples of family planning services are:

• Appointments for birth control, including emergency contraception
• Pregnancy testing and counseling
• Testing and treatment for sexually transmitted disease
• Abortion
• Tubal ligation
• Vasectomy

You can get more information about how to receive these services by calling our Member Services Department or your primary care provider. You can also call the Department of Health Services, Office of Family Planning at (800) 942-1054. The office of Family Planning provides information about family planning services, consultation and referral to family planning clinics.

Prenatal Care - You do not need a referral from your primary care doctor to receive prenatal care from an OB/GYN.

If you are pregnant, you should call and speak to one of our Case Managers about our case management program for pregnant women. For more information about this program please call (800) 809-1350.

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MENTAL HEALTH SERVICES

Mental health services are available for people that suffer with mental illness, depression, grief and/or anxiety. Family counseling services are also available. To find out more about these services call:

Solano County Members:

Napa County Members:

Yolo County Members:

Sonoma County Members:

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DENTAL SERVICES

The dental benefit is not provided through PHC. For more information about the dental benefit, you should call the State of California's Denti-Cal office at (800) 322-6384. Dentists Accepting Denti-Cal

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LANGUAGE 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, Spanish and Russian.

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, Appeal or Hearing".

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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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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.

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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PHARMACY - MAIL ORDER 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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MEDICARE PART D

IMPORTANT INFORMATION FOR PHC MEMBERS THAT HAVE MEDICARE AND MEDI-CAL

Beginning January 1, 2006, everyone with Medicare and Medi-Cal was automatically enrolled into the new Medicare Part D Prescription Drug program. That means that starting January 1, 2006, outpatient prescriptions are covered by Medicare and not by Medi-Cal or Partnership HealthPlan of California (PHC). The Medicare Part D program covers prescriptions that you get from your pharmacy (outpatient prescriptions). Medi-Cal/PHC still pays for your medical care not covered by Medicare.

This means that people that have Medicare and Medi-Cal are automatically enrolled in the Medicare Part D Prescription Drug program and assigned to a Prescription Drug Plan (PDP). If you are not satisfied with your assigned PDP, you should contact the Medicare office at the number listed below to find out if there are other PDP's to choose from.

Under the Medicare Part D Prescription Drug program you are responsible for a drug co-payment for each prescription you have filled. These co-payments are your responsibility and a re not paid by Medi-Cal or PHC.

It is very important that you understand that as of January 1, 2006, prescription drugs are no longer covered by Medi-Cal of PHC. However, prescription coverage is available to you under the Medicare Part D Prescription Drug program. If you choose to disenroll from the Medicare Part D program you will not have drug coverage through Medi-Cal, PHC or Medicare.

If you have questions about Medicare Part D, you can call Medicare at (800) 633-4227 or visit Medicare on the web at www.medicare.gov.

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HELP FOR SUBSTANCE ABUSE

PHC has a program to help you in your substance abuse recovery. This program is open to PHC members who feel they have a problem with alcohol or other drugs. Early intervention and treatment is most helpful - and all you have to do is make a phone call. For help, call:

• (800) 547-0495 or (707) 784-2220 (Solano Members);
• (707) 253-4721 Adults (Napa Members);
• (707) 255-1855 Teens (Napa Members);
• West Sacramento (916) 375-6350 (Yolo Members);
• Davis (530) 757-5530 (Yolo Members);
• Woodland (530) 666-8630 (Yolo Members);
• (707) 523-2242 (Sonoma Members) or Santa Rosa (707) 571-3835.

Kaiser members should contact their doctor or Kaiser's Chemical Dependency Recovery Program in Vallejo at (707) 651-1050 or in Vacaville at (707) 624-2830

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PHC'S UTILIZATION MANAGEMENT (UM) PROGRAM

PHC's Utilization Management ("UM") Program handles all Referral Authorization Forms (RAF's) and Treatment Authorization Requests (TAR's). Your primary care provider uses a RAF to refer you to a specialist for one or more visits. Health providers use a TAR to get PHC's pre-approval for some surgeries, wheelchairs, and other services. These health services need to be approved by PHC for medical necessity. PHC answers TAR's within two working days unless more information is needed. If a TAR is not approved, you will get a letter. You may file a grievance or a State Fair Hearing if your TAR is denied and you don't agree with the decision. If you have questions, call the PHC Member Services department at (707) 863-4120 or (800) 863-4155.

Care that is Right for You

Partnership HealthPlan of California wants you to get the care you need. Decisions made by PHC's Utilization Reviewers are based only on the appropriateness of care or service. Utilization Review means that the HealthPlan reviews the care you have gotten or may get. The Health Plan does not pay for any individual involved in the Utilization Review process to deny care or services to our members. PHC does not encourage or offer incentives for denial of care.

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NEW TECHNOLOGY

There are lots of new developments in medical technology and treatments including new drugs. Many times, new developments lead to better quality of care. Some treatments need to be tested in studies to make sure they are safe. PHC's Technology Assessment Policy describes how the HealthPlan considers new technology. A group of doctors and pharmacists who work with our members decide if there is good scientific proof that a new treatment is better than or equal to those already in use. They also decide if an already approved treatment can be used in other ways. These guidelines are always used.

1. The treatment must be safe. The benefits must be greater than any side effects or risks. It must also be approved by safety groups, such as the Federal Drug Administration (FDA).
2. The treatment must be effective. Does it work? Does it improve the member's health and quality of life?
3. The treatment must have value. If the cost is more than technologies being used, are the benefits also greater?
4. The treatment must be medical in nature. If the treatment is more for convenience or is cosmetic the new technology would not be approved.

The group picks members who would gain most from a new treatment and makes guidelines on the best way to use treatment.

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PHC Quality Program Information for Members

A full description of our Quality Program is available upon request. If you would like more information or a copy of the program evaluation, please call Members Services at (707) 863-4120 or (800) 863-4155

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