Following you will find some of the more frequently asked questions that we receive every day. If you have a question not answered here, please call one of our Customer Service Representatives at (415) 467-9808, Monday through Friday, from 8:30 a.m. to 5 p.m.

• What is an HMO Insurance/Managed Care Plan?
• Who will take care of me if I get sick? How do I access medical care?
• What is a medical emergency condition?
• What do I do in an emergency?
• What should I do if I experience an urgent condition during or after business hours?
• How do I see a specialist or other practitioners who participate with Physicians Integrated Medical Group?
• Questions? How To Contact Us...

Your health plan's HMO (Blue Cross, Blue Shield, Health Net, PacifiCare, or San Francisco Health Plan) has contracted with the Physicians Integrated Medical Group and its integrated network of medical providers to furnish and coordinate all of your health care needs through your Primary Care Physician (PCP). The Primary Care Physician whom you have chosen determines your medical group affiliation.

The Physicians Integrated Medical Group is a managed care provider group consisting of primary care physicians and specialists who practice throughout San Francisco and San Mateo counties. Your PCP is the family practice, internist, pediatrician or general practice physician whom you have selected as your primary physician. Please remember that your Primary Care Physician must coordinate your medical needs, including hospitalizations, laboratory, X-rays, etc.

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Your Primary Care Physician will provide your health care needs and coordinate most, if not all, of your on-going care. Your health care plan member card identifies your PCP and includes his or her phone number. Your health care services will be provided within the Physicians Integrated Medical Group and you will be referred out of network only if a PIMG physician or affiliated hospital cannot render the appropriate care. As a Physicians Integrated Medical Group member, you can access the network of physicians and their respective medical services at Seton Medical Center, California Pacific Medical Center, St. Luke's Hospital, UCSF Medical Center and St. Mary's Medical Center, where your PCP cares for his or her hospitalized patients.

Your PCP, or the corresponding on-call physician, is available 24 hours a day, seven days a week for urgent or emergent medical problems. For medical attention needed after hours or on weekends, please call your PCP. Your call will be returned by either your PCP or by the physician on-call. Keep in mind that if you reach your PCP's answering service when you call for an after-hours or weekend urgent/emergent medical condition, you can always request to have the on-call physician paged to attend your call. Your PCP or the on-call physician will assess your medical status by telephone and will advise you of the method of treatment most appropriate to your situation.

If you have selected a PCP whom you have not yet met, we encourage you to schedule an introductory visit at your earliest convenience so that you can establish a medical history with your new physician. This will benefit both of you if an unexpected illness occurs and you need immediate treatment. We advise you and your family to call your PCP's office for a initial appointment within 30 days of becoming a PIMG member.

We encourage you to discuss the different health educational programs available to you and your family (diabetes management, asthma, etc.) with your physician. Please call your physician's office directly, or call us at (415) 467-9808 for further information.

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An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

1. Serious jeopardy to the health of the individual; or
2. In case of a pregnant woman, the health of the woman and the unborn child; or
3. Serious impairment to bodily functions; or
4. Serious dysfunction of any bodily organ or part.

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In the event of an unanticipated emergency medical condition, go to the closest emergency room, or call 911 for assistance and/or an ambulance. It is appropriate for you to use the 911 emergency response system in your area for assistance when you have an emergency medical condition which requires an emergency response. You do not require prior authorization from your group medical plan administrator for emergency services. Please contact your Primary Care Physician as soon as reasonably possible. If needed, your PCP will coordinate all of your medical follow up care.

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Contact your physician at the telephone number listed on your health plan ID card. Your physician will tell you what to do and where to go. He or she will direct you to the most appropriate place to receive care.

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Under your managed health care plan, specialty, practitioners and allied health services referrals require prior authorization from your PCP before services can be rendered. Female patients may self-refer to any Physicians Integrated Medical Group OB/GYN physician for OB/GYN medical services. An annual Well Woman Exam is a covered benefit for all PIMG female members. As a well-trained and experienced physician, your PCP will manage most conditions; however, when your condition warrants the care of a specialist practitioner or of an allied health service provider, your PCP will refer you to one. Please keep in mind that if you access medical care without prior authorization from your PCP or Physicians Integrated Medical Group, you may be financially responsible for the charges incurred.

All of the Physicians Integrated Medical Group's medical care decisions are based only on appropriateness of care, service and the existence of medical health insurance coverage. The Physicians Integrated Medical Group does not compensate practitioners, or any other individual conducting utilization review for denials of coverage or service, nor for any modification or reduction in services (underutilization). Any medical plan member or public person has the right to request a copy of the criteria used to arrive at any medical decision, particularly if a denial letter is issued to you by the Physicians Integrated Medical Group. Also, as a member, you have the right to request a copy of Physicians Integrated Medical Group's policies and procedures affecting any aspect of your medical care by calling (415) 467-9808. As a Physicians Integrated Medical Group member you can initiate a complaint, a grievance or an appeal regarding any aspect of your care by contacting your medical insurance plan administrator, the Department of Managed Health Care, or us, by letter or phone. A physician or a representative of your choosing can act on your behalf for any of these affairs. Please call the Physicians Integrated Medical Group's Quality Assurance Specialist at (415) 467-9808 for specific complaint or grievance information, to request a form, to obtain a copy of the Quality Management Program, Quality Management Plan or the Physicians Integrated Medical Group's progress in meeting its goals.

The Physicians Integrated Medical Group will never discriminate in treating its members and makes this publicly known with its attention to nondiscriminatory behavior. The Physicians Integrated Medical Group's provision of health care services is not influenced by a member's race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment. The Physicians Integrated Medical Group will accept for treatment any patient in any of the health care services that we provide under the terms on our medical health plan contracts.

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If you have any questions about referrals, authorizations, benefits or billing, you can speak with a Physicians Integrated Medical Group representative at (415) 467-9808; if you have questions regarding utilization issues, please call us. You may also obtain a list of the Physicians Integrated Medical Group's participating providers (PCP's and Specialists) or a copy of your Member Rights and Responsibilities, by calling (415) 467-9808.

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