Basics - How To Use Your Health Plan
CenCal Health wants to make your ability to use your Plan as simple and easy as possible. There are some basic things you need to do as a new or existing member. You can learn more in your Member Handbook (English) / Member Handbook (Spanish).
Here are a few basics you (a new member) need to do:
- Pick your Primary Care Provider
- Keep your appointments
- Establish a good relationship with your doctor and specialty providers
- Call CenCal Health’s Member Services Department when you need help
How to Choose Your Primary Care Provider (PCP)
Choosing a doctor or clinic is the first and most important step. This doctor or clinic is called a Primary Care Provider (PCP). PCPs can be a private practice doctor, a group practice, a clinic, a Rural Health Clinic (RHC) or a Federally Qualified Health Center (FQHC).
Members are provided a listing of all doctors, specialty providers, and hospitals in a book or on this website known as theProvider Directory for Members. The Directory will tell you the address and phone number of each PCP office, what language(s) they speak, their sub-specialty, if they have handicap access, and if they are accepting new patients. If a PCP is not accepting new patients, you can’t choose that PCP unless you have been a patient of that PCP within the last 12 months.
You can call our Member Services Department if you need assistance with choosing a PCP at 1-877-814-1861. Or, if you cannot hear or speak well, please call California Relay at 711 or TTY: 1-833-556-2560. If you do not choose a PCP, one will be automatically assigned for you.
How to Change Your Primary Care Provider (PCP)
If you want to change your PCP, all you need to do is call the Member Services Department and one our Member Services Representative will be happy to assist you and send you a new identification card. The change will be effective the first day of the next month.
When you change your PCP, remember to ask your old PCP to send your medical records to your new PCP. Make sure to tell your new PCP about any special medical needs you have or any medical treatment or appointments that have already been scheduled.
Working with Your Primary Care Provider (PCP)
Call your PCP to schedule a new patient exam as soon as you become a Health Plan member so you can get to know your doctor. You should visit your doctor within 2 months of becoming a Health Plan member. An early check-up is important for children, pregnant women, and people with health care problems. This is also a good time to learn about the services of the office or clinic you’ve chosen.
Make a list of things to ask your PCP, so that you don’t forget important questions.
Show up and be on time for your appointments. If you can’t keep an appointment, please call the office or cancel your appointment at least 24 hours in advance or as soon as possible.
Your health care requires a team effort between you, your PCP, and your PCP’s staff. Your PCP may want to see you before referring you to a specialist. Your PCP will always be in charge of your health care needs and will work together with you and his or her staff to provide you with quality medical care. You may be seen by a Nurse Practitioner or a Physician Assistant who will work with your PCP to make sure you get the medical care you need.
Some things to remember before, during or after visits with your doctor:
- Talk to your PCP about any routine health exams that you may need.
- Tell your PCP about all medications you’re taking, even medicine that you buy without a prescription. Bring the medications with you and show the labels to your PCP.
- Ask your PCP to explain your condition or treatment when you don’t understand.
- Take the medicine that your PCP prescribes as directed and ask if there will be any side effects that you should know about.
- Call your PCP when your medicine doesn’t seem to be helping or if you’re having problems.
- Call the Member Services Department if you have questions or need help in understanding your benefits.
When You Need To See a Specialist
CenCal Health must approve your PCP’s referral:
- When you are referred to an out of area specialist. “Out of area” means a provider or facility that is outside of Santa Barbara or San Luis Obispo counties.
- When your child is sent to a specialist for a service that may be covered under the California Children’s Services, they need to know you are a CenCal Health member.
Always present your Medi-Cal Identification Card and your CenCal Health Identification Card.
When You Need Prior Authorization (Approval)
Examples of services that should be authorized in advance include:
- Non-emergency hospitalization
- Care at skilled or intermediate nursing facilities
- Certain outpatient laboratory and diagnostic imaging procedures
- Certain medications
- Certain medical equipment (for example, wheelchairs, walkers)
Filing A Complaint or Appeal
We Welcome Questions, Complaints, or Suggestions
CenCal Health wants you to have the best possible medical care and service. We welcome questions, complaints, or suggestions about the care you receive. Your comments help to improve the services we provide to you as our member.
In addition, CenCal Health has a staff of Member Services Representatives who are ready to help if you have questions or concerns about your health care coverage or services provided.
How to File a Grievance/Complaint:
If you are unable to solve a problem or concern with your doctor or CenCal Health you may file a grievance/complaint by:
- Calling a Member Services Representative at 1-877-814-1861. Or, if you cannot hear or speak well, please call California Relay at 711 or TTY: 1-833-556-2560.
- Sending your grievance/complaint in writing to:
- Grievance Unit, Attention: Grievance Manager
- 4050 Calle Real, Santa Barbara, CA 93110
- Using our website, see the “For Members” section, under Health Initiative, “How to File a Complaint or Appeal.”
Grievance/complaint forms are available by calling our Member Services Department and a Member Services Representatives can help you file a grievance/complaint. CenCal Health provider offices also have complaint and appeal forms.
It’s important for you to be able to talk to and feel comfortable with your Primary Care Provider (PCP).
There are PCPs in our network that speak a language other than English. We also have bilingual, bi-cultural staff to help you. For help in choosing a PCP that offers services in a language other than English, please look in your Provider Directory for Members. or call our Member Services Department at 1-877-814-1861 and a Member Services Representative can help you. Or, if you cannot hear or speak well, please call California Relay at 711 or TTY: 1-833-556-2560.
CenCal Health encourages you to NOT use family members and friends as your interpreter which is important for your privacy. There is new technology that can provide this service to you via a three way conversation between you, your doctor and an expert interpreter in your preferred language available 24 hours a day, 7 days a week. Your CenCal Health doctor knows how to use these services. This technology is also available for members who need American Sign Language (ASL) services but they must have the telephonic video conference technology on their smart phone.
If ASL members do NOT have this technology, face-to-face interpreter services are available. There may be times when the Health Plan does not arrange or pay for interpreter services. Hospitals are required to arrange and pay for interpreter services in their facility. Face-to face services require two full business days-notice.
Dental and Vision Services
Medi-Cal covers some dental services for children up to age 21, including:
Hospital outpatient services, including anesthesia if it is related to dental care which is covered by CenCal Health and will need prior authorization in order to coordinate with you dentist.
If you have questions or want to learn more about dental services, call Denti-Cal at 1-800-322-6384 (TTY 1-800-735-2922). You may also visit the Denti-Cal website at denti-cal.ca.gov.
Vision services that include eye examinations and glasses for children 20 years of age and under are a covered benefit and provided to your children through CenCal Health every two years. If you are over the age of 21, you may receive an eye examination every two years or as medically necessary, but your eye glasses are not a Medi-Cal benefit. If you have diabetes, retinopathy eye examinations are provided through CenCal Health.
When You Receive a Bill
Steps to follow if you receive a bill:
If you receive a bill from a provider, please do not ignore it. You should first call the provider and make sure they have your CenCal Health insurance information in order to bill the health plan instead of billing you. For more information about which insurance cards you should always present when receiving services, please follow this link.
Next, please call CenCal Health before paying for a bill. You may contact our Member Services Department any time you receive one to discuss it and see if it qualifies for review under our Member Billing Process. Our representatives will be able to tell you if the bill should be sent in for review, or if the bill is your responsibility.
There are situations where you can be billed such as:
- If you ask for and receive services that are not covered by Medi-Cal, such as cosmetic surgery;
- If you do not tell the provider you have Medi-Cal coverage through CenCal Health;
- If you go to a provider that tells you they do not accept Medi-Cal and you tell the provider you want to be seen anyway and that you will pay for the services yourself;
- If you have other insurance and Medi-Cal, and you don’t follow the rules for how to receive services under your insurance.
Important Billing Limitations:
The billing limit for medical services is 1 year from the month of service (month you received care). This means a provider cannot bill CenCal Health after this time period. If you do not contact CenCal Health for assistance with a bill within the year, you will be responsible for payment. For pharmacy billing limitations, please contact the Medi-Cal Rx call center at 1(800)977-2273.
Emergency Services Received in Mexico & Canada:
Services are not covered outside of the United States, except for emergency services requiring hospitalization in Canada or Mexico. If you pay for emergency services that required hospitalization in Canada or Mexico, CenCal Health will only reimburse you the Medi-Cal allowable rate which may be less than you actually paid. Valid receipts and proof of payment will be required.