Important Member Information
The information contained on this page is provided on behalf of
NAMM California and the Independent Practitioner Associations (IPAs) it manages.
The topics below are provided as an overview only and in an effort to inform
members on these specific topics. For additional information on any of the
topics discussed below please contact PrimeCare Customer Service.
Access to Care
Timely availability of care from your primary care provider
will result in swift problem identification, follow-ups on previously identified
issues, and appropriate use of health care resources. NAMM California's managed
IPAs and Medical Groups have established the following standards for access to
care:
Our business model encourages and rewards physician
participation at all levels of the organization to meet common goals. We use our
medical, transactional and technological capabilities to support the local
management of resources by physicians.
Access to Routine Care:
- Preventive/well care appointments or appointments to see new patients
available within 30 days of call
- Non-urgent care appointments for primary care physician (PCP) within 10
business days of patient�s call
- Non-urgent specialty consultation appointments available within 15
business days of patient's call
- Average length of waiting time in the office does not exceed 15 minutes
from arrival time
- Urgent appointments that do not require prior authorization within 48
hours of request
- Urgent appointments that do require prior authorization within 96 hours
of request
- Telephone calls will be answered in a timely manner
Access to Urgent & Emergent Care:
- Answering service with pager or person-to-person coverage 24 hours per
day/ 7 days a week. If automated voice message system is used, the
message must direct patient's to go to nearest emergency room in the
event of a true medical emergency
- The Physician on call will respond within 30 minutes of an
urgent/emergent call
Medical Management Statement
NAMM California's managed IPAs base decisions regarding the
provision of service on the patient's clinical condition, community standards of
care, and the patient's health benefit plan. Decisions are not based upon
physician incentive packages, reimbursement levels or other considerations.
Affirmation
NAMM California's managed IPAs do not base the provision of
care on ethnicity, gender, sexual orientation, race, mental or physical
disability. The provision of care is based only on appropriateness of care and
service and existence of coverage. We do not specifically reward practitioners
or other individuals for issuing denials of care. Financial incentives for
Utilitization Management (UM) decision makers do not encourage decisions that
result in underutilization. Decisions regarding
hiring, compensation, termination, promotion, or other similar matters with
respect to any individual are not made based upon the likelihood the individual
will support the denial of benefits.
Advance Directives
When a member has made their wishes known in regards to
end-of-life care, the patient's treating physician (s) will honor the wishes as
described in the advance directives. The presence of advance directives does not
influence the availability or access to physicians, medical services or covered
benefits except to remain congruent with the wishes stated in the advance
directives. The advance directives can be revoked at any time. More
information
Continuity of Care
When a member's active care may be disrupted by the departure
of a specialty physician from the network, the member will be notified 60 days
prior to the departure of the physician. The member who is impacted by this
transition can call PrimeCare Customer Service who will provide a list of
suitable providers for the member's ongoing care. For members with special
transition concerns, case managers will work with you and your physician(s) to
develop a continuity of care plan.
Member Rights & Responsibilities
The delivery of health care depends upon a mutual partnership
between the member and their primary care physician (PCP). Members have certain
rights and responsibilities and it is very important that as a member you know
and understand them, so you can get the most out of your relationship with your
doctor and be an active partner in the delivery of your health care. View the
NAMM member rights and responsibilities in English
or in Spanish.
Accommodation Services
There are several ways to support members who may have
difficulty communicating with their health care provider:
For non-English speaking members, translation services
are available to assist the member. To access these services, please contact
your Primary Care Physician.
For sensory impaired members, staff can provide information in a manner to
accommodate the deficits. If a non-hearing member needs a sign interpreter one
will be made available to the member. If you have a speech or hearing impairment
and use TTY, please call 711. If the member is sight impaired, the staff will
review any written information verbally. If the member has difficult
understanding or needs re-enforcement, please contact PrimeCare Customer
Service.
Our PCP offices are evaluated to ensure accessibility by members who might have
disabilities.
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