Independent Physician Association (IPA) FAQ
What is an IPA?
An IPA is a network of independent private physician practices who are supported by IPA staff (outside the doctors' offices) to help primary care physicians 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 so you will also have to select a primary care physician.
What's the difference between Emanate Health Independent Physicians and my health plan?
A health plan provides its members with health benefits/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). Emanate Health Independent Physicians 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 in your community.
How do I join Emanate Health Independent Physicians?
Call our Emanate Health Independent Physicians at 877.789.3627 and speak with one of our customer service representatives.
Primary Care Provider (PCP) FAQ
What is a PCP?
A PCP is a 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).
What if I want to change my PCP?
Establishing a strong partnership with your PCP is important. If, for some reason you would like to change physicians, contact the Emanate Health Independent Physicians Referral line at 877.789.3627 or look in our directory for another physician that might be a better fit for your particular needs. Then call the Member Services Department at your health plan or request a PCP change via your plan's secure Internet logon (the phone number is usually displayed on 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.
What if the PCP I want is "closed" to new members?
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.
If I change my PCP will I receive a new card?
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.
When can I see my new PCP?
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.
How do I obtain an authorization to see a specialist?
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.
How does the referral authorization process work and how long does it take?
If a referral is deemed necessary, your PCP will submit to Emanate Health Independent Physicians 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 two categories: routine or urgent (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 is advisable. If so, the specialist will then initiate the authorization request directly to Emanate Health Independent Physicians, 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, Emanate Health Independent Physicians 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 Emanate Health Independent Physicians within 72 hours of receipt from your physician.
Authorizations that are marked "urgent" are processed by Emanate Health Independent Physicians within 24 hours of receipt from your physician. Urgent is defined as any services that are medically needed within two to three days.
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.
How can I be sure my services will be covered?
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 Emanate Health Independent Physicians always checks coverage and benefits before we issue the referral authorization, you can have the peace of mind that the authorized services are covered, provided you are still enrolled in the plan on the date of service.