For your convenience, we have compiled the most commonly asked questions posed to us by our members-along with our answers to each. If you have additional questions you don't see answered below, please call Member Services at (805) 988-5188.
To view a specific topic, please click on one of the links below:
An Independent Physician Association is a network of independent private physician practices who are supported by IPA staff (outside the doctors' offices) to help coordinate comprehensive health care services, health education, disease prevention programs, claims processing and other administrative services for our members and doctors. The IPA is not a clinic and it does not practice medicine. Your physician does!
Similar to a health insurance company, a health plan provides its members with health benefit/coverage for medical, hospital and preventive care services through contracted networks of physicians, hospitals and other health care providers. The health plans we work with are all licensed by the California Department of Managed Health Care and are sometimes referred to as "health care service plans" because, unlike typical insurance/PPO plans, these health plans provide comprehensive prevention and illness coverage with very little out-of-pocket cost to the patient (member) and, most often, without claim forms. SeaView IPA is a network of health care providers that has signed a contract with your health plan to arrange actual medical and health services through our network of independently contracted physicians and other providers.
A Primary Care Physician is a broadly trained and experienced doctor who is trained in Family Practice, General Practice, Internal Medicine or Pediatrics. Your PCP is the physician you select as responsible for providing all of your primary medical care and coordinating any specialty care you may need. Each of your covered family members may select a personal PCP based on services that are most appropriate for individual needs (such as a general practitioner, family practitioner, internist or pediatrician).
Establishing a strong partnership with your primary care physician is important. If, for some reason, you decide that another physician might be a better fit for your particular needs, contact the Member Services department at your health plan or request a PCP change via your plan's secure Internet log-on (the phone number is usually displayed on the back of your health plan member ID card. Phone numbers and Web links can also be found in the "Participating Health Plans" area of this site). Typically, the effective date for the change is the beginning of the month following your request. You may also call our Member Services department before calling the health plan if you would like more information about physicians in our network.
Most health plans allow members the freedom to change PCPs a number of times. Senior (Medicare) members can change their PCP monthly. (However, to ensure optimal continuity of care we don't recommend a monthly PCP change.)
You must select an "open" physician unless you're an already-established patient with that physician. If you are an established patient, under prior coverage, with a PCP who is marked as "closed" then you should write "Established Patient" on your enrollment form or inform your health plan's Member Service Representative of your status with the physician. Your health plan will verify this information with the PCP's office before making an official assignment.
Yes, you should receive a new card from the health plan within a few weeks of changing your PCP. If you don't, please contact your health plan.
You may see your new PCP anytime for any medical condition or preventive care needs, after the effective date established by your health plan. Please call your PCP's office directly to make an appointment. If you are a new member or have changed PCPs, and have not yet received your new ID card, please bring any temporary enrollment forms you may have and/or inform the physician's receptionist of your recent change.
Typically, your PCP is the one to determine that your medical needs require the care of a specialist and will initiate the appropriate referral. If you feel that your health care needs would be best served by seeing a specialist, it's necessary that you contact your PCP to request an authorization. In most cases you will need to have an appointment with your PCP, who will evaluate your need for a referral to a specialist.
If a referral is deemed necessary, your PCP will submit to SeaView IPA an authorization request for either a specialist referral or for complex diagnostic testing (including pertinent chart notes, lab results, X-rays, etc). The authorization will be submitted using one of three categories-Routine, Urgent or Stat. (Remember, care for Emergency Medical Conditions is available immediately and does not require prior authorization). The authorization category is determined by the referring physician based on your current medical condition. (Your physician does not need prior-approval to send you for most lab work or for routine X-rays and diagnostic imaging procedures.) Most physicians use our secure and confidential "Provider Log-in" to send us this information electronically, making the referral authorization process easier and faster for both our physicians and our members.
Once you have been seen by a specialist, that specialist may determine that additional testing, procedures or specialty care are advisable. If so, the specialist will then initiate the authorization request directly to SeaView IPA, keeping your PCP informed of his/her findings and recommendations. For patients who need the ongoing care of a specialist due to chronic or medically complex conditions, SeaView IPA has special processes that allow for authorization of multiple visits or standing referrals to see the specialist for a period of time. In these cases, you may not need to return to the PCP in order to obtain follow-up care from the specialist.
Authorizations that are marked as "routine" are processed by SeaView IPA within 5 business days of receipt from your physician.
Authorizations that are marked "urgent" are processed by SeaView IPA within 24 hours of receipt from your physician. Urgent is defined as any services that are medically needed within two to three days.
"Stat" authorization requests are phoned in to SeaView IPA by the physician's office and processed immediately.
Referral authorizations are processed utilizing InterQualÂ® standardized clinical criteria. Once a determination is made a fax is sent to the referring physician's office and to the requested specialist, notifying both of the outcome. At the same time, a letter is sent to you with instructions on how you should proceed. While it is rare, a referral request may not be approved, usually because the service requested is not a covered benefit by the member's health plan or the requested provider is outside of our network and we already have a qualified specialist to serve the patient's need; in the latter case, the referral would be approved/re-directed to an in-network specialist. Any determination that the service requested is not covered because it is "not medically necessarily" is only made by a physician (typically the Medical Director), never by a non-physician.
If you don't agree with the outcome of your referral request, we recommend you first discuss it with your physician. In some cases, your physician might agree with the decision and advise some alternate testing or treatment first. After the results of the recommended testing or treatment, it may be determined that the requested specialist is appropriate after, or a more conservative treatment may be considered. Your physician may also discuss the decision with our Medical Director.
In addition, the letter you receive from SeaView IPA regarding your referral request will also provide information (including contact numbers and addresses) as to how you may exercise your right to appeal the decision directly to your health plan, with or without agreement from your physician. (See Grievances & Appeals in the Member Services Section.) You may also choose to obtain the services at your own expense. If you have questions about the referral decision or would like to receive information about the review of your particular referral request, you may contact our Member Services Department at 805-988-5188 or via email at MemberServices@svipa.com
Covered services are determined by your health plan and your particular plan's benefit coverage. These should be outlined in the plan materials you received at enrollment. If you have questions about whether or not a service will be covered you should contact your health plan directly. Some services that are generally covered benefits might be subject to a determination that they are "medically necessary". For example, surgery for strictly cosmetic purposes is generally not covered. Similarly, routine physicals are generally covered, unless, you have already had such services within the timeline your health plan has advised for scheduled preventive care services. Because SeaView IPA always checks coverage and benefits before we issue the referral authorization, you can have the piece of mind that the authorized services are covered, provided you are still enrolled in the plan on the date of service.
Please email or call in your address updates to our Member Services Department 805-988-5188 or via email at: MemberServices@svipa.com. Remember, it's also important to notify your health plan of any address changes. If you no longer live or work in Western Ventura County, your health plan will recommend that you select a new IPA or Medical Group.
You must contact your health plan to file a formal complaint/grievance and there are very specific procedures for doing so. Please see Grievances & Appeals in the Member Services section.
An emergency means a severe and sudden medical condition (or injury, active labor or severe pain) that requires immediate medical care to avoid any of the following:
1) Putting the patient's health in serious jeopardy
2) Serious impairment to bodily functions
3) Serious dysfunction or disfigurement of a bodily organ or body part
4) Or, for a pregnant woman, serious jeopardy to the health of the baby
The above definition is based on an average person's (not a trained medical professional) reasonable belief that his or her condition, sickness or injury could result in the above outcome if not treated immediately. If you believe you are having a medical emergency, you should call 911 or go to the nearest medical facility or hospital Emergency Room. This does not have to be a contracted facility. Once your condition is stabilized, you should contact your PCP for follow-up care (e.g., removal of sutures).
Urgent care is for unexpected illnesses or injuries that, while not as serious as an emergency, require prompt medical attention within 24 hours to prevent deterioration of your health. For more detailed information, please see Urgent Care Centers in the "Participating Providers & Health Plans" and Urgent & Emergency Care in the "Health Care Services & Wellness" areas of this site.