A health maintenance organization (HMO) and a preferred provider organization (PPO) are both types of managed healthcare systems. HMO members must select a primary care physician (PCP) from among the HMO member physicians. The PCP provides general care and must be consulted before you can see a specialist, who must also be part of the HMO. PPO members do not choose a PCP and can refer themselves to specialists.
On average, HMOs are the least expensive health option; doctor's visits, preventive care, and medical treatment are given in exchange for a monthly premium as well as a co-payment. PPOs typically come with a higher premium and require that a deductible be met before insurance benefits begin.
When you choose a primary care physician, you also choose your medical group or Independent Practice Association. These groups are formed when doctors decide to work together to serve a community. These physicians agree to participate in an association to contract with specialist physicians, hospitals, health plans, and other healthcare providers to form a network.
Your HMO provides us with your eligibility and benefit information. This enrollment process can take up to 90 days, but please be assured that your benefits are effective from your date of eligibility.
Your health plan is responsible for your demographic and benefit information. You must contact your employer or health plan directly in order to change this information. Your health plan will notify John Muir Health of any changes.
As an HMO member, you can expect to receive an identification card from your health plan as proof of coverage. The ID card will be mailed to you shortly after you enroll. Please take this card with you whenever you seek medical attention.
If your health plan requires a co-payment, it must be paid at each visit. Co-payments may be different depending on the services provided. Please present your insurance card each time you visit a healthcare provider. This includes primary care physicians, specialists, and laboratory services.
Your health plan may require you to pay coinsurance instead of a co-payment. Coinsurance is calculated as a percentage of the allowed amount payable to a physician, and is the patient's financial responsibility. If you are responsible for coinsurance, your physician will generally bill you for it after your visit.
If you have health insurance coverage through your spouse, or have Medicare, please be sure to provide the physician's office with the secondary insurance information.
A primary care physician (PCP) is your first, or primary, source of medical care -- in other words, your personal doctor. When you enroll with John Muir Health, you choose a PCP who will coordinate your healthcare services. The PCP you choose coordinates your medical care, including checkups, referrals to specialists, lab and X-ray services, and hospital admissions. PCP-based care is an effective way to maintain better health. Regular physician visits help build strong, secure doctor-patient relationships.
You can search for a doctor within our network using our Find a Doctor online tool.
Getting a second opinion from a different doctor might give you a fresh perspective and new information and options for treating your condition. Your PCP can refer you to another specialist within our network. You also have the option of selecting an out-of network physician for your consultation.
If you do not agree with a medical management decision, you have a right to file a formal appeal directly with your health plan. If you have concerns regarding quality of care or quality of service, you have a right to file a formal complaint directly with your health plan. You can expect to receive an outcome from your health plan within 30 days for a standard appeal and a response regarding a complaint within 30 days.
A family physician treats adults and children for general medical conditions. Family physicians are trained in dealing with family issues and relationships, and may provide general gynecology services. An internist treats adults 18 and above and specializes in the diagnosis and treatment of diseases. You may select either a family practice or internal medicine physician as your primary care physician.
Pediatricians specialize in the prevention, diagnosis, and treatment of diseases of children from birth to adolescence. Most pediatricians treat children up to the age of 18.
You will need to contact your health plan. Once they have updated your enrollment record, they will provide that information to us. Please make sure to mention that you wish to remain affiliated with John Muir Health. Some physicians belong to multiple medical groups or physician associations and the health plan may inadvertently switch you to another one.
If you have a need for emergency care when you are away from home, seek the necessary care as soon as possible and contact your health plan.
A referral is a written directive from your physician to another in-network John Muir Health physician. The written referral is good for up to six months from the date of issue. An authorization is a request for service that requires formal review by John Muir Health.
Before many types of specialized services are provided, such as a non-emergent hospital admission, surgery, and durable medical equipment, medical necessity is reviewed by John Muir Health on behalf of your HMO. Your physician is familiar with this process and will request prior authorization from us when necessary. Your physician will notify you of the outcome of our decision. It should be noted that an authorization is not guarantee of payment. You must be eligible on the date of service.
It varies, based on the treatment plan, expected outcomes and goals, and patient compliance. Frequency and duration will be determined by the therapist.
Your physician will provide you with a lab requisition slip. The orders will indicate the name of the contracted facility.
Your physician will provide you with a radiology requisition slip. The orders will indicate the name of the contracted facility. Each location specializes in certain services.