An IPA is a group of individual doctors in private practice in your community who have joined together to form an association, in a sense, a "team". This allows you, the patient, to select a primary care physician at a location that is convenient for you and enjoy the special attention given to you at your own doctor's office. PA works with selected providers in our network (specialists, hospital, laboratory, radiology…) within the area you have selected to provide medical services.

Your primary care physician has a history with you and knows your specific health problems. Your PCP can evaluate your medical condition and determine when your diagnosis or your medical problem requires the care of a specialist.

To schedule an appointment, call your doctor’s office during regular office hours. Please call as far in advance as possible to ensure optimum service.

Your doctor respects your time and makes every effort to honor scheduled appointments on time. However, unforeseen situations or emergencies do sometimes arise. We ask your patience if this does happen and your appointment runs later than expected. To expedite processing, please bring your health plan card or enrollment form to each appointment as well as a list of all of your medications and your medical history.

A reminder: You are responsible for your copayment at the time of your visit.

You can call Physician Associates Customer Services department to receive a direct referral for the following types of services:

*If a Covered Benefit

Your doctor will discuss your condition with you to determine if you should see a specialist. He or she will submit an authorization request to PA if that treatment is deemed medically necessary.

PA reviews all authorization requests based on medical necessity, benefit coverage and whether or not the recommended specialist is available through your individual health plan. PA will respond to your referral within 5 working days after the request is received. If for some reason you have not heard from PA in that time period, call PA as soon as possible or, if an emergency arises, call your doctor. Responses to an urgent (not immediately life threatening) referral request will be called into your PCP's office within 48 hours. Please do not schedule appointments prior to receiving an authorization.

PA encourages you to make every effort to schedule an appointment immediately after receiving written approval as soon as possible. If you absolutely need an extension, call Customer Services at (626)817-8300.

Whenever possible call your PCP. If you are stricken with a life threatening illness or injury, dial 911 immediately or go to the nearest hospital emergency department. If the situation is serious enough to require immediate care but is not life-threatening, call your PCP immediately to arrange services. In the unlikely event that you are not able to reach your doctor, call PA at (800)303-3133 to access the after hours nurse between 5:30pm to 8:00am.

Your copayment for the emergency room can be higher than an office visit copayment, and will be printed on your insurance card.

If you are "out of area", which means you are more than thirty miles outside of your selected PA service area, contact your Health Plan at the number on your insurance card.

NOTE: Call 911 or go directly to a hospital emergency room when you are in a life threatening situation such as a heart attack, stroke, or are severely bleeding!

Your doctor's request is reviewed and a decision is made by PA’s - Utilization Management Department that is comprised of knowledgeable nurses and doctors. There are very few requests that are denied.

Physician Associates receives numerous referral requests for coverage of medical services. We want you the member, to be assured that PA uses evidence-based guidelines and criteria when making authorization decisions. The major criteria and guidelines we use include (but are not limited to):

• Apollo Guidelines
• Milliman Care guidelines
• Medicare guidelines
• Health plan guidelines
• Medical and local policy determinations
• Physician Associates Clincal Guidelines

If the review involves a clinical issue, no one other than a physician can make a determination to deny coverage for the services requested. Criteria used for a specific review decision is made available to you upon request by calling PA’s Customer Service Department at (800) 303-3133.

Physician Associates Appropriate Utilization of Care Affirmation Statement:

• Utilization decisions are based only on appropriateness of care and service.
• No person involved in the authorization process may receive compensation for denials.
• No person involved in the authorization process may receive an incentive, either financial or non-financial, directly or indirectly to encourage denials.
• The utilization process must include systems to monitor for underutilization for services. The process shall include analysis of monitoring reports, identification of issues, development of improvement action plans to address these issues and finally, evaluation of the actions taken.

You have the right to appeal a denial by filing a grievance with your health plan.

For Commercial Members, your Health Plan requests that you submit your grievance or appeal within 180 days from the postmark of your notice of denial.

For Senior members, your Health Plan requests that you submit your grievance or appeal within 60 days from the postmark of your notice of denial.

You or someone you designate (your authorized representative) may submit your grievance verbally or in writing. You can call your Health Plan at the number listed on the back of your Health Plan ID Card.

Submitting a Grievance

Please submit a copy of your denial notice and a brief explanation of your situation, or other relevant information to your Health Plan. Your health plan will document and process your appeal or grievance and provide you with a written notification of the decision. You may write, call or fax your grievance to your Health Plan.

An HMO member is only responsible for payment of services in three situations:

Contact PA’s Customer Services Department at (626)817-8300 and the Representative will assist you in resolving the claims matter. Make sure you have the following information available at the time of the telephone call: your insurance identification number, the authorization number for the services you are being billed for and the physician's name.

It is important you notify your health plan, PA and your PCP’s office of any address changes. This will assure that your authorizations will be sent to you in a timely manner and avoid possible scheduling delays. You may contact PA with your address change by e-mailing Eligibility Department or by faxing your request to 626 817-8391. Please include your member ID on all correspondence.