HMO Insurance Frequently Asked Questions
What is a "PCP" and do I need one?
What does my PCP do if I need a referral?
What happens after my doctor makes an "outside referral"?
What if I want to see a physician outside of SCMC?
What if a specialist I am seeing outside of SCMC wants me to have Tests or procedures?
What about when I am sick? Who should I see?
What if I want to go to the Emergency Room?
What if I am out of the area and need medical care?
Will the care I receive at SCMC be different because I have HMO insurance?
Welcome to Santa Cruz Medical Foundation! We are pleased that you have chosen SCMF as the primary medical group with your HMO.
Your choice of health plans will affect how you access medical care. In choosing an HMO, you have the responsibility to understand your benefits, how to access them and to know what services are excluded. Please read these "frequently asked questions" to learn more about how our HMO plans work. If you have chosen an HMO it is also important that you familiarize yourself with the benefits of your plan by reading the Evidence of Coverage provided by the health plan.
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What is a "PCP" and do I need one?
A "PCP" is a Primary Care Physician, generally in the specialties of Family or General Practice, Internal Medicine or Pediatrics. If you have previously seen a Santa Cruz Medical Foundation (SCMF) PCP, you will automatically be assigned to your regular physician. If you are new to SCMC, you will need to choose a PCP. If you are unsure or need assistance in choosing a PCP, call the Managed Care Office at 458-5500.
Your PCP will be able to help you if you need a referral to a specialist or need a test or procedure that is not done at SCMF. It is a good idea to make a "get acquainted visit" with your PCP if you are new to the Clinic or have never met your PCP. This means your PCP will know who you are if you need to be seen because of illness, or need your PCP's help with a referral.
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What does my PCP do if I need a referral?
Your PCP can work with you to determine your medical needs. If your PCP determines that you need to see a physician or other provider who is part of SCMF, your PCP will notify the specialist's office. It is a good idea to find out if your PCP needs to see you each time you need a referral, or if you can call your PCP to request that a referral be made.
A different kind of process is done for referrals to Physical Therapy, Occupational Therapy, Speech Therapy, Plastic Surgery, and certain Educational Classes. These are processed as "outside (or external) referrals"; see below.
If your PCP determines that you need to see a specialist who is not a part of SCMF, he or she may make a referral known as an "External" or "Outside" Referral to a Specialist.
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What happens after my doctor makes an "outside referral"?
This will depend on the nature of the referral. The referring doctor's office will enter a referral request into our computer system. A nurse and/or physician will review your referral request and make a decision based on coverage and medical necessity criteria specific to your plan. A determination may not be made immediately if all pertinent information is not available. Every effort is made to complete the referrals in a timely fashion. At SCMC, the Managed Care Department makes these determinations based on appropriateness of care and service. SCMC does not compensate practitioners or individuals for denials and does not offer incentives to encourage denials of referrals. SCMF recognizes that inappropriate denials or underutilization of services may have serious consequences for managed care members.
After your referral has been reviewed, you will receive notification by mail regarding its status. You should look the letter over to see if the referral was approved or denied, and to see what is written in "Comments/Limitiations" where specific information may be included.
You may call the Managed Care Office at 458-5500 to check on the status of your referral request. Your physician's nurse or medical assistant is not able to give out information regarding the status of your referral.
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What if I want to see a physician outside of SCMC?
Under the terms of your HMO health plan at the Santa Cruz Medical Foundation, all services including Lab and X-ray must be obtained at SCMF unless otherwise approved in advance in writing. Generally, referrals for services outside of SCMC will not be approved unless the medically necessary covered services are not available at SCMC. Any referrals for services outside of SCMC must be authorized in advance in writing by SCMC with an approved Specialist Referral Pre-Authorization Form. A verbal comment or handwritten note from a physician is not sufficient for authorization. Outside services must be received from participating providers unless authorized in advance by SCMC.
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What if a specialist I am seeing outside of SCMC wants me to have tests or procedures?
You or the specialist will need to contact the SCMF physician who referred you or your PCP in
order to request these tests. If the tests can be done at SCMF (such as most lab tests, X-rays, CT scans, MRI's, ultrasounds, EKG's), they must be done at SCMF unless otherwise approved in advance in writing. If the tests your "outside specialist" wants are not done at SCMF, you will need to get prior authorization, as with all "outside referrals".
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What about when I am sick? Who should I see?
It is always a good idea to check in with your PCP's office when you are ill. At SCMF, we recognize that good continuity of care is important to your on-going health. If your PCP is not available, particularly in the evening or on the weekends, SCMF is fortunate to have Urgent Care facilities at the locations listed on our flyer or in our web site. These do not include the Emergency Rooms at Dominican Hospital or Watsonville Hospital. Urgent Care hours are convenient for most visits (the hours at the Main Clinic facility are 8 a.m. to 9 p.m. daily, including holidays.) You do not need prior authorization to go to the SCMF Urgent Care facilities.
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What if I want to go to the Emergency Room?
In emergency situations: Call 911 or go to the nearest hospital. An emergency is defined as a sudden, serious and unexpected illness, injury or condition, including severe pain, requiring immediate medical attention.
If your situation is not so severe: if you cannot call your primary care physician or SCMF, or you need medical care right away, go to the nearest center or hospital.
If you are unsure of whether an emergency medical condition exists, you may call your physician for assistance. SCMF has physicians available 24 hours a day, seven days a week, to respond to your phone calls regarding medical care that you believe is needed immediately. They will evaluate your situation and give you directions about where to go for the care you need.
Except in an emergency or other urgent medical circumstances, the covered services of the HMO plans must be performed by Santa Cruz Medical Foundation, or must be authorized by SCMC to be performed by others. You may use other providers outside SCMF only when you are referred to them by SCMF.
It is critical that you contact your physician at SCMF as soon as you can after receiving emergency services outside of SCMF. SCMF will evaluate your circumstances and make all necessary arrangements to assume responsibility for your continuing care.
Follow-up services (after emergency care) must be performed or authorized by SCMF, or they will not be covered.
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What if I am out of the area and need medical care?
As above, contact the Foundation and speak with your physician's office, or with the physician on-call if it is after Foundation hours. If you receive care at an emergency room out of our area, your physician should be notified within 48 hours.
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What about continuity of care?
SCMF has a policy regarding continuity of care. If you have been receiving care from a health care provider, you may have the right to keep your provider for a designated time period. Please contact your HMO’s customer service department, and if you have further questions, you are encouraged to contact the Department of Managed Health Care, which protects HMO consumers, by telephone at its toll free number, 1-888-HMO-2219, or at a TDD number for the hearing impared at 1-877-688-9891, or online at www.hmohelp.com. A copy of SCMF’s written policy will be provided upon request, by calling: 831- 458-5500.
Thank you again for choosing Santa Cruz Medical Foundation!
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