We appreciate the trust you have placed in us by selecting Palomar Health Medical Group as your health care provider.

Palomar Health Medical Group contracts with a number of health insurance plans to provide your care. The health insurance plans require that Palomar Health Medical Group to provide you with various types of information. For your convenience, we have included this information here on our website. If you have any questions, or would like a printed copy, please call 858.613.8910.

The Advance Health Care Directive became the legally recognized format for a living will in California on July 1, 2000. An Advance Health Care Directive is the best way for a patient to make sure their wishes are known and considered in the event they are unable to speak for themselves. Palomar Health Medical Group will provide patients interested in learning more about Advance Directives with referrals to information sources. A patient with an Advance Directive shall not be refused treatment nor discriminated against.

• Utilization Management decision-making is based on the appropriateness of care and service and existence of coverage.
• Palomar Health Medical Group does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service.
• Financial incentives for utilization management decision makers do not encourage decisions that result in under- or over-utilization.

Palomar Health Medical Group has processes in place to provide access to staff for members and practitioners seeking information about the Utilization Management (UM) process and the authorization of care.

Utilization Management Member Services staff are available at least eight (8) hours a day during normal business hours (8:00 AM – 5:00 PM Monday through Friday) to receive inbound communication regarding UM issues. They can be reached at 1-858-499-2565. Member services staff are authorized to accept collect calls from members regarding UM issues.

The UM Department has a voice mail box to accept after hour messages. Calls are returned the following business day during the week. Weekend messages are returned on Monday morning.

Palomar Health Medical Group has a Complex Care Management Program in place for members of United Healthcare West and United Healthcare Medicare Solutions. The goal of this program is to help members regain optimal health or improved functional capacity. This program is designed for members with complex medical needs that require an intense level of medical management and care coordination. Clinical data sources are reviewed monthly to identify candidates. Members who feel they may qualify for this service and would like to self refer should contact their primary care physician.

Provision of health services is not influenced by member race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.

Effective 1/1/2009, Palomar Health Medical Group will strive to comply with all contracted health plans in providing language assistance services to limited English proficient (LEP) HMO members in accordance with Senate Bill 853 and applicable revisions to the Knox Keene Act.
If an LEP member contacts Palomar Health Medical Group administrative offices or customer service either in person or via the telephone, the staff member at the encounter will follow the applicable workflow for the contracted health plan.

Contracted health plans will provide Palomar Health Medical Group with an approved “Notice of LAP Services” which should accompany non-standard vital documents that are issued by Palomar Health Medical Group.

When Palomar Health Medical Group staff members receive a request for a copy of document issued by Palomar Health Medical Group in accordance with UM or Claims delegation processes, the staff member will:

Document the date and time of the request.
Forward the request to the appropriate department (UM or Claims)

• Urgent request or service: One business day
• Non-urgent or post-service request: Two business days

These timeframes are necessary to ensure that the health plan can comply with the request with the 21 calendar days required by the regulations.

Palomar Health Medical Group’s goal is to fairly compensate physicians for care that meets high professional standards. Physicians are strongly encouraged to discuss all health care options with their patients. There are no incentives to withhold such information nor are there incentives to withhold medically necessary services.

A combination of physician compensation methods are used at Palomar Health Medical Group. Physicians are paid a base salary for their services, and can receive additional compensation based on their workload as well as the achievement of specific quality and customer satisfaction goals.

All health plans require that Palomar Health Medical Group have an evaluation process in place before a patient can receive certain types of services. This is called prior authorization. The types of service that must undergo the prior authorization process will vary according to the terms of your individual health plan. You can obtain this information from your health plan’s member guide.

When required by your health plan, Palomar Health Medical Group must make a determination as to whether certain care is medically appropriate before it is delivered. In general, this process is required for non-emergency care and certain procedures and treatments.

Your Primary Care Physician (PCP) is responsible for providing primary care services to you. When services of a specialty provider are deemed medically necessary, the PCP is responsible for referring you in accordance with Palomar Health Medical Group’s referral procedure. Review of certain referral requests (based on the terms of your health plan contract) will be the responsibility of the Utilization Management Department and the Utilization Management Physician.

PCPs may directly refer you for a consultation with a contracted specialty physician who may perform, without prior authorization, specific services in the office and services covered under your health plan. Physicians are required to refer you to Palomar Health Medical Group’s contracted providers for laboratory, radiology, physical therapy, home health, durable medical equipment, and other medical services.

Requests for specific procedures will require your PCP or specialist to submit a referral request to the Utilization Management Department. Referral requests should be submitted with all available pertinent data and documentation. Referral requests are reviewed for medical necessity by qualified medical professionals. When needed, physician consultants from the appropriate specialty areas will be used for the review of complex cases. Only a licensed physician may determine that a request for medical care should be denied because it is not medically necessary.

The Utilization Management Department will confer with your health plan as needed in ambiguous cases, as well as cases involving benefit policy determinations. Review of requests involving new medical technologies (i.e., new medical procedures, drugs, devices) will be the responsibility of your health plan.

You may receive a copy of the Medical Necessity criteria/guidelines used in the determination of the services requested for you. To obtain a copy of the Medical Necessity criteria/guidelines used in making the determination on the requested services you should contact the Utilization Management Department Customer Service at 1-858-499-2565 during normal business hours (8:00 AM – 5:00 PM Monday through Friday) to request a copy be sent to you.

At Palomar Health Medical Group, we strive to meet or exceed your expectations for quality health care and service. Should we fail somehow, please let our physicians and staff know what your concern is. Our staff and physicians want to take care of problems and concerns in a timely manner, and should communicate with you regarding the status of the concern if it cannot be resolved right away.

If you are still dissatisfied with our care or service, please contact the Member Services department at your health plan. The phone number is usually provided on your health insurance card. Once the issue is documented, your health plan’s Member Services will notify our Quality Management Department. The Quality Management Department will work together with your health plan to assist in the resolution of your concern.

You have the RIGHT to:

• Considerate and respectful care.
• The ability to regularly schedule an appointment with your own physician and to know in advance the time, location and the name of the individual, if different.
• Receive and understand information about your illness, treatment and recovery chances.
• Right to receive information about Palomar Health Medical Group (e.g., its services, providers, and members’ rights and responsibilities).
• Participate in decisions regarding your medical care.
• Candid, unrestricted discussion of appropriate, medically-necessary treatment options for your conditions, regardless of cost or benefit coverage, so you can give informed consent or refuse.
• To know the name of the person who will carry out the procedure/treatment. Except in emergencies, this information must include a description of the procedure/treatment and the risks, alternate courses of treatment/non-treatment and those risks.
• Privacy concerning your medical care program. Casework is confidential and should be carried out discreetly. You have the right to be informed of the reason any person is present.
• Confidential handling of all communications/records relating to your care. Written permission must be obtained before medical records can be made available to anyone not directly concerned with your care.
• Expect a reasonable response to any reasonable request made for service.
• Voice complaints or appeals about the medical group or the care provided.
• Exercise these rights without regard to your gender; cultural, economic, educational, or religious background; or the source of payment for your care.
• Have all patients’ rights apply to the person who may have legal responsibility to make decisions regarding medical care on your behalf.
• Make recommendations regarding the Palomar Health Medical Group’s patient rights and responsibilities policies.
• Access services and information in alternative format in the language that is prevalent in Palomar Health Medical Group’s population.

You have the RESPONSIBILITY to:

• Communicate openly with your physician and provide information needed to care for you.
• Establish a continuous and satisfactory relationship with your physician.
• Help your physician maintain accurate and current medical records.
• Consult your physician prior to receiving medical care unless in a life-threatening situation.
• Make certain you understand the care directions and participate in developing treatment goals.
• Consider possible consequences of not following or refusing the recommended treatment.
• Know what medication to take, why, and the way to take it.
• Keep scheduled appointments or give adequate notice of delay or cancellation.
• Present insurance information prior to receiving services.
• Pay all applicable co-payments at the time service is provided.
• Pay all charges for non-covered services.
• Become an active partner with Palomar Health Medical Group in meeting your healthcare needs.

• In addition to the specialists located at our Poway locations, Palomar Health Medical Group contracts with a number of additional specialists. Prior authorization is required to receive care from these specialists. Their addresses can be obtained from your health plan’s provider directory, or by calling Palomar Customer Service 858.499.2565