Health Care LA, IPA for Members

HCLA IPA represents your physicians and health centers. We contract with federally qualified health centers, community clinics, rural health centers and some private physicians throughout Los Angeles County. Your health plan (for example Anthem Blue Cross, Care 1st, Health Net, LA Care and Molina) requires you to choose a primary care physician (PCP) or health center. You’ve chosen a PCP with HCLA IPA. Your PCP and HCLA IPA will be coordinating all of your care, using our specialty and hospital networks. Your health plan determines your benefits, for example your co-payment amount when you see a physician or go to an emergency room. If you have your insurance through your employer, your employer and insurance company work together to determine what your monthly premium will be and the premium is paid directly to your insurance company by you or your employer.

Your primary care physician and/or health center (PCP) is always the first place you should contact when you have a medical condition requiring attention. If you think you have the flu, phone your PCP. If you have knee pain, phone your PCP. Your PCP will most likely want to see you before determining if you should be referred to a specialist for a specific condition. The only exception to this is if you feel you are experiencing a life threatening emergency – for example sudden onset of chest pain. If this should occur, you should always phone 911 or go to the nearest emergency room. Go to the tab on our Website to review a list of our preferred hospitals and urgent care centers.

Scheduling an Annual Health Exam for you and your family is very important. This visit it is a good time review your medical concerns with your provider. It allows you to meet and put a face to the person and organization that you and your family will utilize for all your future healthcare needs. This is also an important health benefit that your health plan encourages and provides to you. So please take advantage of this service!

Your PCP will submit an authorization request to HCLA IPA. We will then determine which of our specialists is the most appropriate for your care. You will then receive an authorization in the mail. Routine authorization requests are reviewed and completed within 5 working days. If your PCP advises us that the request is urgent, the review will be completed within 2 working days. If the request is urgent, you will be notified as soon as possible but within 24 hours. Remember – in order for a claim to be paid, you must have an authorization for the service.

HCLA IPA does offer services, called self-referral, that do not require an authorization as long as you self-refer to a participating specialist. These services include gynecological consultations, well woman exams and OB care – first visits. We also offer several direct referral services. This means that your PCP is able to send you directly to a HCLA IPA contracted specialist for additional services.

Not all plans or services require a co-payment, but when they do, all co-payments are made to the provider of service at the time services are received. Remember, your insurance company determines your co-payment amount. This rate is not established by your physician or HCLA IPA.

If you have received an authorization for services or if you have self-referred for a service that does not require authorization, like gynecological consultations, well woman exams or first visits for OB care, you should not receive a bill. There are times when labs or radiology departments may send their patients a bill because they did not get complete information at the time of service. Whenever you receive a bill or statement please phone our Customer Service Department. We do not want you paying something that could have been sent to you due to clerical error.

Emergency services are those health care services provided to evaluate and treat medical conditions where immediate medical care is required. An emergency medical condition can consist of one or more of the following symptoms: Difficulty breathing, shortness of breath; chest pain/pressure; seizures (convulsions); fainting, trouble talking, dizziness; changes in vision; confusion; uncontrolled bleeding; severe/persistent vomiting or diarrhea; coughing up or vomiting blood; suicidal feelings; unusual abdominal pain; suspected broken bones; eye pressure; asthma attach; possible ingestion of poison, or medicine overdose. If you or a family member should experience a life threatening emergency, it is very important that you go to the nearest emergency room. Most emergency rooms will contact your insurance company to advise of your condition, discuss your treatment plan and also determine where bills should be sent. Upon your return home, be sure to contact your primary care physician (PCP) or health center provider to advise them of your illness while away from home. It’s important that your medical records are updated and if you should need to receive continued care for the condition, your PCP will be the one coordinating any care you need. Your health center may also call you to schedule a follow up visit with a provider to review your current health care needs.

If you are admitted to a hospital, an inpatient team of physicians called Hospitalists will be managing your care in conjunction with specialists, and your primary physician who will be notified and informed of the care you are receiving. Upon discharge, you will be notified to arrange a follow up appointment with your PCP. If other specialist visits are required, or supplies needed in your home, the HCLA IPA team of inpatient case managers will be coordinating your specific needs.

We do want to assist each and every member in every way possible. If you have any questions and/or concerns, do not hesitate to contact our Customer Service Department at (818) 702-0100 any time between the hours of 09:00 a.m. and 05:00 p.m. Monday through Friday. <strong>Appeals:</strong> If you are not satisfied about a decision regarding the denial of services or payment. Please refer to the Evidence of Coverage (EOC) provided by your health plan for detailed instructions on how to file an appeal. Or, you can call your health plan directly. <strong>Grievances:</strong> If you are dissatisfied with Health Care LA, IPA and/or any of its providers, including quality of care concerns, please contact your health plan and file a formal grievance. Health Care LA, IPA strives for excellence in healthcare and will work closely with your health plan to ensure the highest quality of care and strive to meet your satisfaction. If you have any further questions, you may contact our Customer Service Department.