Obtaining Decision Making Criteria
To discuss a denial, request an appeal, or obtain a copy of the criteria used to make the determination, please call our Member Services Department at (657) 206-8700
Criteria used for a specific review decision is made available to providers, members and the public upon request by calling Member Services Department at (657) 206-8700
Utilization decisions are based only on appropriateness of care and service
No person involved in the authorization process may receive compensation for denial of care.
No person involved in the authorization process may receive an incentive whether financial or non-financial, directly or indirectly to encourage denials.
The utilization management process will include systems to monitor for over/under utilization of services. The process shall include analysis or monitoring reports, identification of issues, development of clinical care management plan, and evaluation of the actions.
Member Rights and Responsibilities
As member/patient of ProCare, you have many key rights, but also some important responsibilities. ProCare is committed to seeing to it that your rights are respected at all times—by upholding your responsibilities, you can ensure a satisfying member experience.
- To exercise these rights without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information or source of payment
- To be treated with respect, and with recognition of your dignity and privacy
- To be provided with information about your IPA, its services and the healthcare service delivery process
- To be informed of the name, qualifications and titles of the physician that has primary responsibility for coordinating your care, and to be informed of the names, qualifications and specialties of other professionals who may be involved in your care
- To have 24-hour access to your primary care physician (PCP) or covering physician
- To receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, as well as prospects for recovery in terms that are understandable to you
- To be informed of continuing healthcare requirements following office visits, treatments, procedures and hospitalizations
- To actively participate in decisions regarding your healthcare and treatment plan. To the extent permitted by law, this includes the right to refuse any procedure or treatment (if refused, an explanation will be given by your provider and will address the effect(s) that this will have on your health)
- To have access to personal medial records based upon state and federal requirements
- To be informed of non-emergent costs of care and receive an explanation of your financial obligations prior to incurring the expense (including co-payments, deductibles and co-insurance)
- To examine and receive an explanation of bills generated for services delivered to you
- To be informed of applicable rules in the various healthcare settings regarding member conduct
- To express opinions or concerns regarding your IPA or the care provided; to offer recommendations for change in the healthcare delivery process by contacting your IPA Member Services Department; to have a timely and organized system for resolving member complaints and formal grievances
- To be informed of the member grievance and appeals process
- To change your PCP by contacting your health plan
- To receive reasonable continuity of care and be given timely and sensible responses to questions and requests made for service
- To be able to formulate advanced directives for healthcare
These member rights shall apply to any person that has legal responsibility to make healthcare decisions for you. Members also have the right to be represented by parents, guardians, family members or other conservators if they are unable to fully participate in their own treatment decisions.
Our partnered physicians share our vision of providing high quality care to our members. To find out if your physician belongs to ProCare’s network, please call (657) 206-8700.
If your physician is not in our network but is interested in joining, please have them call us and we will be more than happy to assist in enrollment.
Advanced directives refer to a personalized healthcare treatment plan that allows your physician, family and friends to know your care preferences in times when you may not be able to express them yourself. These important wishes include special treatment that you may or may not want at the end of your life as well as your desire for diagnostic testing, surgical procedures, cardiopulmonary resuscitation and organ donation.
Although these may not be easy decisions to make, by considering your options now you can ensure the quality of life that is important to you and avoid the grief, stress and arguments that may arise when leaving your loved ones to guess as to your wishes when critical medical decisions need to be made.
For more information on Advance Directives in the state of California, click here.