Referrals and Approvals

Your PCP will talk to you about your healthcare needs. If your PCP cannot give you the services you need, he/she will refer you to a specialist or hospital for treatment. Your PCP will request the referral for you.

You may self-refer for certain covered services. No referral or approval is required from your PCP or California Health & Wellness for:

• Preventive care
• Urgent or emergency care
• Family planning
• OB/GYN
• HIV testing and counseling
• Treatment for a sexually transmitted disease
• Abortion

You may receive benefit coverage for these services whether or not the doctor is in the California Health & Wellness provider network.

No. If you need ongoing care from a specialist because of a serious or life-threatening problem, the specialist can ask California Health & Wellness for a standing referral.

Some conditions may need ongoing care from a specialist. Examples of health problems that could get an extended referral are serious cases of cardiovascular disease, asthma, diabetes, Multiple Sclerosis (MS) or HIV/AIDS.

California Health & Wellness will allow your PCP to give a standing referral for ongoing care to a specialist in the California Health & Wellness network when:

• The specialist in the California Health & Wellness network agrees to a treatment plan for you.
• The specialist provides your PCP with updates on your condition and treatment plan.
• The specialist’s services to be provided are part of the benefits covered by California Health & Wellness.

In most cases, we will make a decision about the referral within five (5) working days. If we do not have all of the information we need to make a decision, it may take up to fourteen (14) calendar days. If you think you need a standing referral, talk to your PCP.  For more information on specialty providers or extended referrals, call Member Services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number).

NOTE: If your specialist refers you to another specialist, your specialist may need to obtain authorization by California Health & Wellness and your PCP.

You have to get California Health & Wellness approval for:

• Hospitalization (but not for emergency and urgent care services)
• Services out of the California Health & Wellness service area  (but not for emergency and urgent care services)
• Outpatient surgery, long-term therapy or specialized treatments

Your PCP or specialist will ask us for approval before you get the services. When you need care, always start with a call to your PCP, except in medical emergencies. Some covered services may require approval by California Health & Wellness before services are provided (called “prior approval”). This includes services or visits to an out of network provider. Home health services and some surgeries also need to be reviewed.  Your doctor can tell you if a service needs review. The list of services needing approval is on the California Health & Wellness website at www.CAHealthWellness.com. You can also call Member Services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number) to see if something needs to be reviewed by California Health & Wellness.

Your doctor will give us information about why you need the service. California Health & Wellness will look to see if the service is covered and that it is appropriate.

We will make a decision regarding your provider’s request for authorization as soon as possible based upon your medical condition, and no longer than five (5) business days from receiving the request and all of the necessary clinical information. If we do not have all of the information we need to make a decision, it may take up to fourteen (14) calendar days. However, if the request is urgent, we will make a decision within three (3) business days of the receipt of the request.

We will let you and/or your doctor know if the service is approved or denied. If you or your doctor are not happy with the decision, you can ask us to make a second review.  This is called an appeal. See the “What to Do If You Are Not Satisfied” section of this handbook for more information about appeals.

If there are any major changes to the prior authorization process, we will let you and your doctors know right away.

You are covered only for the healthcare services that you need. If our Medical Director determines you do not have a medical need for certain services, we will not approve those services. A decision is based only on the appropriateness of care and benefit coverage. California Health & Wellness does not reward Medical Directors or other individuals involved in decision making for denials of coverage. There are no financial incentives to encourage decisions that result in less care.

If we do not approve a requested service, we will tell you why. You will receive a letter explaining why the requested service was not approved. If you do not agree with the explanation given, you may appeal the decision by filing a formal appeal. For information on how to file an appeal, see the “Filing an Appeal” section of this handbook.

To learn more about how we make those decisions, call Member Services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number) and ask for a copy of our medical necessity guidelines.

If you see a provider that does not have a contract with us, California Health & Wellness will not pay for the care you receive from that provider without prior approval.

Covered services that you receive must be medically necessary. This means getting the right care, at the right place, at the right time. California Health & Wellness uses standard guidelines to make sure you are receiving medically necessary services.  California Health & Wellness does not reward its network providers or their staff to deny or delay care.

You have the right to a second opinion about your treatment choice. This means talking to a different doctor about an issue to see what they have to say. The second doctor is able to give you their point of view. This may help you decide if certain services or methods are best for you.

You can get a second opinion from a network provider for certain services, including:

• Surgery
• Treatment or diagnoses of serious or life-threatening conditions
• Complex cases or cases with conflicting test results
• Cases where you – the Member – does not respond well after an appropriate amount of time

To get a second opinion, you can request to be referred to doctors specializing in that area of medicine. Your PCP or California Health & Wellness Member Services staff can help you find a doctor to give you a second opinion. You may choose any California Health & Wellness network provider. Once you decide who you want to see, ask your PCP to refer you. Then make an appointment to see this doctor.  If the second opinion is different from the first opinion, you or California Health & Wellness can ask for a third opinion.

If you are unable to find a doctor in-network qualified to see you, we will help you find a doctor outside the network. If you need to see an out-of-network provider for the second opinion, it must be prior approved by California Health & Wellness. There is no cost to you for a second or third opinion.

If you do not know which doctor to see for a second opinion, ask your PCP or call Member Services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number) for help.

California Health & Wellness will let your PCP and/or specialist know when your request for a second opinion is approved. For a routine condition, we will let your PCP and/or specialist know within five (5) business days of your request. If we do not have all of the information we need to make a decision, it may take up to fourteen (14) days. If your case is urgent, we will let your PCP and/or specialist know within 72 hours of your request.

If we deny your request, we will let you, your PCP and specialist know within 24 hours of our decision. If you do not agree with our decision, you can file an appeal. For more information, see the “What to Do If You Are Not Satisfied” section of this handbook.

You do not need to ask us for approval first before getting emergency or urgent care. You do not have to see a network provider for emergency or urgent care.

Urgent care is not emergency care. Urgent care is needed when you have an injury or illness that must be treated within 48 hours. It is usually not life-threatening, yet you cannot wait for a visit with your PCP.

Only go to the emergency room if your doctor tells you to go or you have a life-threatening emergency. When you need urgent care, follow these steps:

• Call your PCP. The name and phone number are on your California Health & Wellness Member ID card. Your PCP may give you care and directions over the phone.
• If it is after hours or a weekend and you cannot reach your PCP, call NurseWise at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number). You will be connected to a nurse.  Have your California Health & Wellness Member ID card number handy. The nurse may help you over the phone or direct you to other care. You may have to give the nurse your phone number. During normal office hours, the nurse will assist you in contacting your PCP.
• If you are told to see another doctor or go to an urgent care center bring your California Health & Wellness Member ID card. Ask the doctor to call your PCP or California Health & Wellness.

If you think you have a health emergency, call 911. You are not required to call your doctor before you go to the emergency room. Do not use the emergency room for routine (regular) healthcare.

California Health & Wellness covers emergency medical services 24 hours a day, 7 days a week, whether provided inside or outside of the California Health & Wellness service area. Emergency services do not need approval from California Health & Wellness and are provided at no cost to you.

Emergency services include treatment of an injury or an onset of what reasonably appears to be an emergency medical condition. An emergency arises when the lack of medical attention could be expected to result in jeopardy to your health or, in the case of a pregnant woman, the health of her unborn child.

It is okay if the hospital does not belong to the California Health & Wellness network. You can use any hospital if it is an emergency.  You or someone acting on your behalf should call your PCP after your visit to the Emergency Room. This helps your PCP to provide or arrange for any follow-up care that you may need. We will help you get follow-up care. Call Member Services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number).

When to Go to the ER:

• Broken bones
• Gunshot or knife wounds
• Bleeding that will not stop
• Severe chest pain or heart attack
• Drug overdose
• Poisoning
• Severe Burns
• Convulsions or siezures
• Trouble breathing
• Shock (you may sweat, feel thirsty or dizzy or have pale skin)
• Suddenly unable to see, move or speak
• You are pregnant, in labor and/or bleeding

When NOT to Go to the ER:

• Flu, colds, sore throats and ear aches
• A sprain or strain
• A cut or scrape not requiring stitches
• Diaper rash
• To get more medicine or have a prescription refilled

You may need hospital care after an emergency to stabilize your condition. This is called Post-Stabilization Care. Such care does not require prior authorization. However, California Health & Wellness must be notified within 1 business day after you are admitted to the hospital from the emergency room.

The hospital will ask you for your California Health & Wellness Member ID card. If you don’t have your California Health & Wellness Member ID card, tell the hospital to call us at 1-877-658-0305.

It does not matter whether you receive the emergency care in or outside of the California Health & Wellness network. We will still cover services to make sure you are stable after an emergency. Once you are stable after an emergency, we may transfer you to a hospital or provider in our network.

Your PCP must provide follow-up care when you leave the hospital. For maternity-related emergency services, please see the “Pregnancy and Maternity Services” and “Health and Vision Services Covered by California Health & Wellness” sections of this handbook.

If you have an emergency when you are not in the California Health & Wellness service area, you can get emergency services at the nearest emergency facility. Emergency services do not require a referral or approval from your PCP.  Emergency services are not covered outside of the United States, except for emergency services requiring hospitalization in Canada or Mexico.

If you are admitted to a hospital not in the California Health & Wellness network, we have the right to transfer you to a network hospital as soon as it is medically safe to do so.

area. Routine care outside of the California Health & Wellness service area is not covered.

In most cases, you need to get care within the California Health & Wellness network and within the California Health & Wellness service area.

Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn, Imperial, Inyo, Mariposa, Mono, Nevada, Placer, Plumas, Sierra, Sutter, Tehama, Tuolumne, and Yuba counties.

While out-of-network emergency services do not need approval from California Health & Wellness, most other covered services from out-of-network providers need prior approval by California Health & Wellness. Although, urgent/emergent care, family planning, abortion and some other out of network services do not. We will first check to see if there is a network provider that can treat your medical condition. If there is not, we will help you find an out-of-network providerIf you have questions, call Member Services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number).

If no California Health & Wellness network provider can give you the services you need, you can get those services from a provider outside our network.  But first, your PCP must ask California Health & Wellness for approval. If your case is urgent, we will let your PCP and/or specialist know within 72 hours. For non-urgent cases, we will let your PCP and/or specialist know within five (5) business days. If we do not have all of the information we need to make a decision, it may take up to fourteen (14) calendar days.