Prior Authorization and Out of Network Coverage

What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Physician (PCP) in IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)?
You can get services such as those listed below without getting approval in advance from your Primary Care Physician (PCP).

  • Routine women’s health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
  • Flu shots as long as you get them from a network provider.
  • Emergency services from network providers or from out-of-network providers.
  • Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
  • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.)

How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:

  • Oncologists care for patients with cancer.
  • Cardiologists care for patients with heart conditions.
  • Orthopedists care for patients with certain bone, joint, or muscle conditions.

You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use.

What if a specialist or another network provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider.

How to get care from out-of-network providers
When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Physician (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.

IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

Information on this page is current as of September 30, 2016
H5355_CMC_17_07258 Approved