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-up 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.
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.
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.
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.