PATIENTS/PROVIDERS

Your Health Care Provider
The patient-doctor relationship is integral in keeping our patients healthy. So we understand it’s important to find a physician that’s a right fit for you. To arrange an appointment, please call the physician’s office directly. If you have more specific questions or need more guidance, please contact our Member Services Department at (661) 371-2790
Patient/Member Rights
As a member of QualCare IPA, you have responsibilities and rights. For more information, please click the link to download the complete document. Complaints (also referred to as Grievances or Appeal) can be filed with your health plan, over the phone or in writing, about the care provided without discrimination. You may expect problems to be fairly examined and appropriately addressed. If your health problem is urgent, or if you already filed a complaint and are not satisfied with your health plan’s decision, contact the Help Center at the Department of Managed Health Care (DMHC). An urgent problem is a serious threat to your health. You can also file a complaint with the Help Center if your HMO does not make a decision within 30 days.

Download Patient Rights and Responsibilities PDF

HIPAA Notice of Privacy Practices
The HIPAA Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for her purposes that are permitted or required by law. It also describes your rights to access and control your protected health information (PHI). “Protected health information (PHI)” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. For more information on the Privacy Practices, please click on the downloadable PDF.

Download HIPAA Notice of Privacy Practices PDF

What to Bring to Your First Visit
Our physicians want to make your first visit a success and are interested in learning as much as possible about your current health status. Please arrive a few minutes early so you have time to fill out appropriate paperwork. If you are insured, the office staff will ask to see your insurance card. You should bring to your first visit the bottles of all medications or a list with the names of the medications you are currently taking. If you have not already arranged for your medical records to be transferred, please do so as soon as possible.
 

Affirmative Statement Regarding Incentives

QualCare IPA distributes annually an affirmative statement about incentives to all members and to all practitioners, providers and employees who make utilization management decisions, affirming the following:

 

• Utilization Management (UM) decision-making is based only on appropriateness of care and services and existence of coverage.

• The organization does not specifically reward practitioners or other individuals for issuing  denials of coverage or service care.

• Financial incentives for UM decision makers do not encourage decisions that result in  underutilization.

• Incentives, including compensation, for any person are not based on the quantity or type of denial decisions rendered.

 

For questions regarding this statement please call the Member/Provider line at (661) 371-2790.

Utilization Management
Members and physicians have the right to request Medical Group policies and procedures and criteria used to authorize, modify or deny healthcare to members. A reviewer will be available to discuss decisions with providers and members. Utilization criteria is available to our providers, members and the public upon request by contacting the Utilization Management Department at (661) 371-2790 or toll free at (855) 375-7825 (TTY:711)

 

• UM staff is available 8 hours a day during normal business hours (Monday thru Friday, 8:00 am – 5:00 pm) for inbound calls regarding UM issues

• Utilization Management and Quality Management work plans and programs are available for review upon request

• Collect calls regarding UM issues will be accepted by UM staff if necessary by calling (661) 371- 2790 or call toll free at (855) 375-7825 (TTY:711)

• Providers are not prohibited from advocating on behalf of members or advising a member on medical care.

 

We allow open provider-member communication regarding appropriate treatment alternatives and do not penalize providers for discussing medically necessary or appropriate care for the member.

Language Assistance
Effective January 1, 2009 CA law (SB 853) and its accompanying regulations require that health plans establish and support a Language Assistance Program (LAP) for enrollees that are limited English proficient (LEP). All insurance carriers now provide free translation services in multiple languages for you or your covered family members. Call your health plan’s customer service number listed on the back of your insurance card for information about translation assistance available for medical visits and for health care materials. QualCare also offers language assistance: (661) 371-2790 (TDD/TTY)

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