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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.
  • Have paid for medication and/or a co-pay.

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?

Newborn Appointments

  • Infants discharged from hospital in less than 48 hours of life after delivery should be seen within two business days of discharge.

Non-urgent Primary Care Appointments

  • These appointments include prenatal care, preventive visits, and follow-up visits. Appointments should be provided within 10 business days of the request.

Urgent Care appointments

  • Appointments should be provided within 48 hours of the request.

Emergency care

  • Emergency treatment must be available immediately to all members 24 hours a day. During hours when PCP offices are closed, members should be directed to an after hours or emergency care location depending on the nature of the problem.

Specialty Care

  • Medically necessary specialty care will be provided within the plan service area whenever possible. If a medically necessary specialty service is unavailable within the service area, plan staff will coordinate specialty care outside of the service area and/or network. Appointments should be provided within 15 business days of the request.

Non-Urgent Non-Physician Mental Health Care

  • Appointments should be provided within 10 business days of the request.

Non-Urgent Ancillary Services

  • Non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition should be provided within 15 business days of the request.

Preventive Dental Care

  • Appointments should be provided within 40 business days of the request.

Non-Urgent Dental Care

  • Appointments should be provided within 36 business days of the request.

Urgent Dental Care

  • Appointments should be provided within 72 hours of the request.

Telephone Access, Triage and Screening

  • Triage & screening by phone – office provides or arranges for the provision of 24/7 care or uses the Health Plan’s 24/7 triage service.
  • Triage & screening waiting time- not to exceed 30 minutes. 
  • Wait time to speak to a health plan customer service representative – not to exceed 10 minutes.

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 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.

Kaiser Members: Members assigned to Kaiser should use the Kaiser Advice Nurse Program. For More information about the Kaiser Advice Nurse program, please call the Kaiser Phone number on you Kaiser ID card.

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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.

For Partnership HealthPlan (PHC) Members who are NOT assigned to Kaiser or DO NOT have Medicare Part B

Inpatient Mental Health Services

The County Mental Health Department will continue to provide inpatient mental health services.

Outpatient Mental Health Services

Starting on January 1, 2014, Partnership HealthPlan of California (PHC) will provide outpatient mental health services to our members through Beacon Health Strategies.

    Beacon will:

    • Help you understand your mental health and substance abuse benefits
    • Talk to you about your treatment choices
    • Help you find mental health providers in your area
    • Give you phone numbers to your County Mental Health Department.

You can call Beacon at anytime at (855) 765-9703

Who do I call to learn more about getting mental health care?

You can call Beacon at (855) 765-9703 and a Beacon representative can help you learn more about your mental health benefits and locate a mental health provider.

For Partnership HealthPlan (PHC) Members who have Medicare Part B or are assigned to Kaiser

Members with Medicare PartB: Mental health services will continue to be provided by the County Mental Health Department

Members assigned to Kaiser: Kaiser will continue to provide mental health services.

If you have any questions about how to get mental Health Services, please call PHC's Member Services Department at (800) 863-4155.

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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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FREE LANGUAGE SERVICES

Partnership HealthPlan of CA would like our members to speak to us and to your doctors in your own language. When you have a doctor's appointment, you should have a Qualified Health Interpreter, if you need one. We will provide one at no cost to you. It is best to not use family or friends to interpret for you. You may choose face-to-face or phone interpreter service. Please give three days notice to schedule face-to-face appointments. Your doctor can use our phone interpreter service at any time. Contact us at (707) 863-4120 or (800) 863-4155 to access the service. Members as well as providers can request interpreter services.

Member Materials

You may receive written materials in a language you can read. Most are written in English, Spanish and Russian. If you cannot read any of these languages, or are not getting materials in your preferred language, let us know. You may also receive materials in an audio format or other alternative formats at your request.

Personal Information

In order to better serve you, and to know more about our members, it helps us to know your race and the preferred language that you speak and read. You are not required to provide this information to us, but it would help us arrange your services. To see if we have your correct information, if you find it is not correct, contact us at (707) 863-4120 or (800) 863-4155 to update your information.

Customer Service

When you call Partnership HealthPlan, let us know what language you prefer to speak. If we cannot speak your language, we will use an interpreter at no cost to you. Our staff speaks many languages, including Spanish, Tagalog, and Russian. We use a telephone language service for interpreting other languages.

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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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.

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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REIMBURSEMENT FOR MEDICATION AND/OR A CO-PAY

Contact the PHC Member Services Department within 15 days from the date of service to determine if you are eligible for a reimbursement.

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HELP FOR SUBSTANCE ABUSE

PHC offers the following resources that may help you in your substance abuse recovery. These programs are 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:

Solano County

(707) 784-2220

 

Napa County

(707) 253-4412 Adults; (707) 255-1855 Teens

 

Yolo County

(916) 403-2970

 

Sonoma County

(707) 565-7450

 

Mendocino County

(707) 472-2637 (AODP)

 

Marin County

(415) 755-2345

 

Lake County

(707) 274-9101 (North Lake area)
(707) 994-6494 (South Lake area)

 

Del Norte County

(707) 464-4813

 

Humboldt County

(707) 476-4054

 

Lassen County

(530) 251-8108

 

Modoc County

(530) 233-6319

 

Shasta County

(530) 245-6411 Perinatal Treatment Services
(530) 244-7074 Empire Recovery Center/(Downtown Redding)
(530) 275-1076 Empire Recovery Center/(Shasta Lake)
(530) 365-8523 Right Road Recovery Prog. (Anderson & Enterprise)
(530) 722-1114 Visions of the Cross (Enterprise)

Siskiyou County

(530) 841-4890

 

Trinity County

(530) 623-1362

 

Kaiser's Chemical Dependency Recovery Program:

Solano & Napa County:  Vallejo at (707) 651-1050 or in Vacaville at (707) 624-2830
Sonoma County:  Santa Rosa (707) 571-3835
Marin County:   San Raphael (415) 444-3522
Yolo County:  South Sacramento (916) 525-6100 – Sacramento (916) 482-1132

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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 five 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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MEMBERS WITH MEDICARE AND MEDI-CAL

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 are 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 or 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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Enrollment Center - MyBenefits CalWin and C4Yourself Benefits

MyBenefits CalWin and C4Yourself are online application systems that allows you to apply for benefits. The sites are secured and all your information will be private and safe. To learn more about the services go to your county listed below:

MyBenefits CalWin - Solano, Sonoma & Yolo

C4Yourself - Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Shasta, Siskiyou, Trinity & Modoc

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