Central California Alliance for Health | Living Healthy | December 2018

HEALTHY 4 To help members communicate better with their doctors and us, the Alliance provides both telephone and face-to-face interpreting services, and translation of written member information, at no cost. Members can ask for: ❱  ❱ A trained sign language interpreter ❱  ❱ A trained language interpreter ❱  ❱ Written information in braille, large print or audio format ❱  ❱ Information written in a language they can understand If you need or have questions about the Alliance’s Language Assistance Services, please call the Alliance Member Services at 1-800-700-3874 . For the Hearing or Speech Assistance Line, call 1-800-735-2929 (TTY: Dial 7-1-1 ). Many terms are used in health care, and it can be confusing to understand them all. We want to make sure you know how to get services that are covered by your plan, so here is some information that should help. Referral. If you are assigned to an Alliance Primary Care Provider (PCP), you must have a referral to see another doctor. There are some exceptions to this. See “Chapter 3: How to get care” in your Member Handbook for a complete list of services. If your doctor thinks you need to see another doctor, he or she will fill out what is called a Referral Consultation Form. Your doctor sends a copy to the doctor you are being referred to and a copy to the Alliance. The referral is how the other doctor and Confused by referrals and authorizations? Alliance’s Language Assistance Services the Alliance know your PCP has approved the visit. If we don’t have a referral, we will not pay the claim from the other doctor. Authorized referral. In most cases, your PCP will refer you to a doctor in our service area. Our service area includes Santa Cruz, Monterey and Merced counties. If your PCP refers you to a doctor out of our service area, he or she will need to get approval from us in advance. This is called an authorized referral. It is called this because we have to authorize (approve) the referral before you can see the other doctor. If you are an Alliance IHSS member, you will also need an authorized referral if your PCP is referring you to a doctor who is not contracted with the Alliance—even if the doctor is in our service area. Alliance members who are enrolled in the California Children’s Services Program will also need an authorized referral for specialty care. Prior authorization. The Alliance has to approve some services, procedures, medications and equipment before you get them. This is called prior authorization. The provider who is going to perform the service must send us a request for prior authorization, letting us know what you need and why. The provider can send it electronically, by fax or by mail. We will review the request and any medical records the provider sends. If the service, procedure, medication or equipment is medically necessary and a covered benefit, we will approve the request. We will let the provider know, and then you can get the service. If we deny a request, we will let you and the provider know. You will be able to file an appeal if you disagree with our decision.