DEAR MEMBER

Welcome! We are pleased to have you as a member of our Independent Practice Association (IPA).

Our IPA is managed by MSO, Inc. of Southern California.  The health plans you have chosen or were assigned to have provided you with an enrollment and welcome packet when your benefit started.  The Health Plan Welcome Packet should include information about your assigned Primary Care Provider (PCP) and his/her office address and phone number.  This Welcome Packet should also have included the Evidence of Benefit (EOC) for the benefit you chose or were assigned to.

As a reminder, if your Primary Care Provider does not contact you within 60 days of your enrollment with your Health Plan and his/her office, please contact him/her to schedule your Initial Health Assessment.   This is a visit when your Primary Care Provider will do a complete check-up and physical and decide if you need additional visits by him/her or to be referred to a specialist. 

We are providing you with some additional information: If you have questions regarding your health plan, your primary care provider or your benefits, please contact the IPA management company, MSO, Inc. of Southern California (“MSO, Inc.”)  at 1-(800) 551-1319 or 1- (626) 656-2370. MSO, Inc. can also assist you with questions regarding your referrals to specialists and claims paid on your behalf.

MSO, Inc.’s normal business hours are Monday to Friday from 8:00 am to 5:00 pm, excluding Holidays.  If you are hearing-impaired, please use the TTY/TDD, please call 711.

There is an after-hours answering service to take calls and contact the IPA Medical Director(s) for urgent matters.  However, if you have an emergency, please call 911 or go to your nearest emergency room.  

Thank you for choosing our IPA and we hope that we can provide you with great customer services. 

Members and public may obtain criteria used in decision making by contacting the UM Department  

Monday – Friday 8:00am – 5:00pm by calling 1-800-551-1319 ext. 122 TTY 711 

Member Rights and Responsibilities

·       Ask for and receive information about services provided by each IPA and Medical you are assigned to, participating practitioners, providers, Member rights and responsibilities, and how to use your health plan benefits.

·       Be treated in a courteous and respectful manner that reflects recognition of your privacy and dignity as a person.

·       Wait no more than 30 seconds to speak to a Member Services representative during normal MSO, Inc. business hours.

·       Upon request receive information about MSO, Inc. staff and staff qualifications for health management programs.

·       Receive interpreter services at no cost to you. You also have the right not to use family members or friends as interpreters. Minors should not be used as interpreters unless it is a medical emergency.

·       Receive medically necessary covered services without regard to race, religion, age, gender, national origin, disability, sexual identity or orientation, family composition or size, or medical condition or stage of illness.

·       Receive family planning services, services at Federally Qualified Health Centers or Indian Health Centers, sexually transmitted disease (STD) services, and emergency services outside your IPA or Medical Group network as stated in Federal law.

·       Receive emergency or urgently needed services outside network when medically necessary or when authorized by your IPA or Medical Group.

·       Receive emergency care whenever necessary and wherever you need it.

·       Receive Sensitive Services such as family planning or mental health care in a confidential way.

·       Access minor consent services

·       Choose a primary care doctor within the IPA/Medical Group contracted with chosen health plan.

·       To have a confidential relationship with your doctor.

·       Receive information from your IPA or Medical Group that you can understand.

·       Upon request receive Member information materials in alternative formats including Braille, large print, and audio.

·       Make recommendations about Member rights and responsibilities policies.

·       Participate with your doctors and other practitioners in decision making about your own health care.

·       Talk openly with your doctor and other practitioners about your medical condition and appropriate or medically necessary treatment options for your condition regardless of the cost or what your benefits are.

·       Decide about your care, including the decision to stop treatment or services, or stop participating in health management programs.

·       Decide in advance how you want to be cared for in case you have a life-threatening illness or injury.

·       Be informed by your IPA or Medical Group network regarding advance directives and to receive information from your IPA or Medical Group network regarding any changes to that law. The information shall reflect changes in state law regarding advance directives as soon as possible, but no later than 90 days after the effective date of change.

·       Review, request corrections to, and receive a copy of your medical records (your doctor may charge a fee for copies of records and other forms).

·       Keep your personal and medical information and records confidential, unless you say differently, and know how your IPA or Medical Group network your information confidential.

·       Make complaints and appeals without discrimination about  your IPA or Medical Group network providers, or your care. MSO, Inc. will help you with the complaint and appeal process. You have the right to choose someone to represent you during the grievance process and for your complaints and appeals to be reviewed as quickly as possible and be told how long it will take. Medi-Cal Members have the right to request a State Fair Hearing or an expedited Fair Hearing for urgent cases. Call the Department of Social Services Public Inquiry and Response Unit at 1-800-952-5253 or TTY 1-800-952-8349.

·       Request an Independent Medical Review from the Department of Managed Health Care (DMHC) if you disagree with your IPA or Medical Group network ' decision to deny, delay, or modify a service that your doctor or other practitioner requests.

·       Request an External Independent Review if a service or therapy was denied on the basis that it was considered experimental or investigational. If you have any questions about these procedures, see section Member Satisfaction of this EOC, or call MSO, Inc.

·       Have his/her IPA or Medical Group network act as your patient advocate.

·       Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.

·       Disenroll from your IPA or Medical Group network.

·       Request a second opinion about a medical condition.

·       File a grievance with your IPA or Medical Group network if your language needs are not met.

·       If you are a Native American Indian, you have the right to not enroll in a plan, not be restricted by a plan in your right to access Indian Health Facilities, and to disenroll from a plan without cause.

Members have the following responsibilities:

·       Be familiar with and ask questions about your health plan coverage. If you have a question about your coverage, call MSO, Inc.

·       Follow the advice and care procedures indicated by your doctor, your IPA or Medical Group and the program. If you have a question about these procedures, call MSO, Inc.

·       Request interpreter services at least 5 working days before a scheduled appointment.

·       Call your doctor or pharmacy at least 3 days before you run out of medicine.

·       Cooperate with your doctor and staff and treat them with respect. This includes being on time for your visits or calling your doctor if you need to cancel or reschedule an appointment.

·       Understand that your doctor's office may have limited seating for patients and caregivers only.

·       Give accurate information (to the extent possible) to your IPA or Medical Group, your doctor and any other provider in order to help you receive the best care possible.

·       Understand your health problems and work with your doctor and other practitioners in developing mutually agreed-upon treatment goals, to the degree possible.

·       Ask your doctor questions if you do not understand what they are saying to you.

·       Work with your doctor to make plans for your health care.

·       Follow your IPA or Medical Group and instructions for care that you have agreed on with your doctors and other practitioners.

·       Immunize your children by age two (2) years and always keep your children's immunizations up to date.

·       Call your doctor when you need routine or urgent health care.

·       Care for your own health. Live a healthy lifestyle, exercise, eat a good diet, and don’t smoke.

·       Avoid knowingly spreading disease to others.

·       Use your IPA or Medical Group grievance process to file a complaint. Call MSO, Inc. Member Services to file a complaint.

·       Report any wrong doing or fraud to your IPA or Medical Group by calling MSO, Inc. Compliance Department or the proper authorities.

·       Understand that there are risks in receiving health care and limits to what can be done for you medically.

·       Understand that it is a health care provider's duty to be efficient and fair in caring for you as well as other patients.

Notice of Non-Discrimination or Financial Incentive

IPAs and Medical Groups under the management of MSO, Inc. of Southern California and VitalLinks, Inc. do not reward providers, practitioners or employees for issuing denials of coverage or service.  All denials must be based strictly on insufficient medical appropriateness in accordance with the IPA/Medical Group’s Clinical Guidelines or as not covered benefit under the Health Plan’s Evidence of Coverage.  Terms under which a practitioner may be entitled to a bonus or incentive pay cannot influence his/her decision to withhold, delay, or to deny necessary service.  Utilization decisions are based on appropriateness of care and service and existence of coverage.

MSO/VitalLinks does not provide financial incentives for UM decision makers that encourage or result in under-utilization. 

Financial incentives are not used as a means to encourage barriers to care and service.

Practitioners are ensured independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion, or any other similar matters.

 UM Committee members and staff making UM decision sign this attestation affirming their agreement.  This standard covers any practitioner, provider, staff member or delegate who is subject to financial incentives for making UM decisions.  Staff members confirm that a member’s health care is not compromised in the decision making process.

Documents, and/or information, submitted to the Utilization Management Department for approval, denial or modification do not discriminate against race, ethnic/national identity, gender, age, sexual orientation, types of procedures performed or payor sources.

Members and providers can inquire with their providers regarding any UM related issues and about obtaining a copy of the IPA/Medical Group’s Clinical Guidelines, Policy and Procedures when a service or treatment requested is authorized, modified, or denied.

If you have any questions, please contact MSO Inc. of Southern California Toll Free at 1 (800) 551-1319, TTY 1 (800) 735-2929 between the hours of 8:00 am to 5:00 pm. Thank you.