Frequently Asked Questions – Arta Health Network
1. What is Arta?
2. How do I choose a primary care physician (PCP)?
3. How do I make an appointment with my physician?
4. What should I bring to my first visit to my physician?
5. What is the difference between a referral and an authorization?
6. Do I need an authorization to see a specialist or to receive other services?
7. How do I get an appointment with a specialist?
8. When may I see an Arta specialist physician without a referral?
9. May I request services using “out-of-network” providers or facilities?
10. How long is an authorization valid?
11. How do I change or update my enrollment information?
12. Which health plans is Arta Health Network contracted with?
13. What hospitals are affiliated with Arta Health Network in Orange County?
14. What is the difference between emergency and urgent care services?
15. When is it appropriate to seek emergency room services?
16. When is it appropriate to seek urgent care services?
17. What do I do if I have an urgent medical need after my physician’s office hours?
18. What are the locations of Arta’s contracted urgent care centers?
19. What if I have a need for medical services while I am outside of Orange County?
20. What is the difference between a family physician and an internist?
21. How do I know if Arta Health Network physicians accept my health insurance plan?
22. How do I get prescription medications/refills processed through my physician’s office?
23. Can I change my primary care physician if I am not satisfied?
24. If I am not satisfied with the care I am receiving from my physician(s), how do I file a grievance or complaint?
25. If I disagree with a denial of either an authorization or a claim, how can I appeal the denial?
26. How do I file an appeal or grievance?
27. Should my teenager see a pediatrician?
28. Can you tell me my benefit coverage and co-payment information?
29. How can I be sure services are covered by my health plan?
30. How do I find out if I am eligible with my health plan?
31. What is a case manager?
32. What is HIPAA?
33. What are advance directives for health care?
34. What are my rights?
35. May I request copies of my medical records?
Arta is a general term used to define the two independent practice associations (the Arta IPAs) comprised of Arta Health Network (AHN) and Arta Western Medical Group (AWMG). Combined, these affiliated entities represent one of the largest managed health care provider networks in Orange County, California, serving 75,000 HMO, Medi-Cal, Medicare and Healthy Families members.
You must choose a Primary Care Physician (PCP) who is contracted with Arta Health Network. Your PCP will be responsible for coordinating all of your health care needs, including referrals to specialists and other services. To designate your PCP and obtain a current member identification card with your PCP selection, you must contact your health plan's member services department (please refer to the "Health Care Resources & Links" page contained in this website).
3. How do I make an appointment with my physician?
Call your PCP’s office directly to schedule an appointment.
You should bring a copy of your health insurance card, a list of your current medications, your co-payment for an office visit and information about your medical history. Confirm your enrollment with your health plan or with AHN’s Customer Service Representative at 1-800-780-8879 Monday through Friday, from 8:00 AM to 4:30PM, prior to your appointment time.
A referral is a written directive from your physician to another contracted, in-network Arta Health Network provider. The written referral is good for up to six months from the date of issue unless otherwise indicated.
An authorization is a request for service that requires formal review by Arta Health Network-designated utilization review staff before many types of specialized services can be provided, such as a non-emergent hospital admission, a surgical procedure, the provision of durable medical equipment, infusions, and certain tests. Benefit coverage, member eligibility, and medical necessity are reviewed by AHN on behalf of your health plan. Your PCP and specialist physicians are familiar with this process and will request prior authorization from AHN when necessary. AHN reviews these requests and responds to your physician promptly. You will receive a formal letter detailing the outcome of our decision along with specific valid authorization to-and-from dates. It should be noted that an authorization is not a guarantee of payment. You must be eligible for such services on the date of service.
You may or may not need an authorization depending on your health plan's benefit plan. It is always best to confirm the need for an authorization by contacting your health plan or Arta Health Network’s Customer Service Representative at 1-949-260-6500, Monday through Friday from 8:00 AM to 4:30 PM. In some cases, payment for services may be denied if not pre-authorized.
Certain medical conditions may require that you see a specialist. In most cases, your Primary Care Physician will make that determination and will request a referral on your behalf. Some health plans give members the ability to self-refer for certain specialties without authorization. You should always check with your health plan to determine your covered benefits and the ability to self-refer prior to your appointment.
The following do not require a referral from the PCP if provided within AHN’s contracted-provider network:
-- Women may self-refer to an AHN-contracted obstetrician/gynecologist.
Arta Health Network has contracted with high-quality, "in-network" providers and facilities for all services. In the event that a particular service is not available in-network, your PCP, specialist or ancillary service provider will request prior authorization from AHN to use an "out-of-network" provider for such service. Unless provided in an emergency situation, out-of-network services will generally not be covered unless pre-approved. Our goal is to ensure that you receive timely, high-quality care from our excellent network of contracted providers whenever possible.
You will receive an authorization letter by mail that will inform you of the timeframe for which your authorization is approved.
Changing your address or adding a dependent must be coordinated directly through your health plan. Arta Health Network is electronically linked to all of our contracted health plans and they transmit your enrollment information to us on a regular basis. In some cases, especially with large employer groups, you simply need to notify your employer, who in turn electronically notifies your health plan. Your revised or updated enrollment information is then transmitted electronically to AHN.
Aetna, Anthem Blue Cross, Arta Medicare Health Plan, Blue Shield of California, CIGNA, Health Net, and MD Care.
Arta Health Network’s Orange County hospital network is based on your health plan’s network of contracted hospitals. You are encouraged to contact your health plan’s member services department listed on your health plan member identification card or call AHN's Customer Service Representative at 1-800-780-8879, Monday through Friday from 8:00 AM to 4:30 PM, to learn about Orange County hospitals affiliated with your health plan.
Emergency services are required as a result of unforeseen injury or acute illness for which delay in treatment would result in a permanent physical impairment or loss of life. Chest pains or excessive bleeding may be an example of emergency services.
The term emergency medical condition means a condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person with an average knowledge of health and medicine should reasonably expect the absence of immediate medical or psychiatric attention to result in: 1) serious jeopardy to the health of the individual (or unborn child); 2) serious impairment to bodily functions; or 3) serious dysfunction of a bodily organ or part.
Urgent Care is defined as those services required as a result of unforeseen injury or acute illness that requires immediate attention, for which delay in treatment would NOT result in a permanent physical impairment or loss of life.
If you experience a life-threatening injury or sudden illness for which delay in treatment would result in permanent physical impairment or loss of life, immediately call 911 or go to the nearest hospital emergency room. Chest pains, excessive bleeding and broken bones would be situations where your condition would warrant emergency room treatment. In all other situations, contact your PCP who has coverage 24 hours a day/seven days a week, and describe your symptoms. You will be directed to the appropriate level of care by your PCP. Inform the emergency room staff that you are a member of Arta Health Network, the name of your health plan, and your primary care physician's name, so that your care can be effectively coordinated among contracted AHN physicians. This will also help to ensure that your primary care physician will be notified of the results of your emergency room visit.
16. When is it appropriate to seek urgent care services?
You should go to an urgent care center that is contracted with AHN if a condition arises during your PCP’s non-business hours, and you do not feel that it can wait until your PCP’s office opens. You should always contact your primary care physician first, as some may offer after-hours coverage, and/or your PCP may be able to assist you over the phone.
Call your primary care physician and ask the exchange to contact your physician for direction. If your physician is not on-call there will be a designated on-call physician available to direct you.
Please visit our "Urgent Care Centers" page contained in this website for locations in Orange County.
If you have an emergency medical condition, immediately call 911 or go to the nearest hospital emergency room. In all other situations, contact your health plan for further directions at the number(s) listed on your health plan membership identification card.
A family physician treats both adults and children. Family physicians are trained in dealing with family issues and relationships, and may provide general gynecology services. An internist treats mostly adults 18 years and older, and specializes in the diagnosis and treatment of disease.
You may contact AHN’s Customer Service Representative at 1-800-780-8879, Monday through Friday from 8:00 AM to 4:30 PM, to confirm that AHN providers are contracted with your health plan.
If you are a new patient, bring your medications with you on your first visit to your PCP. Your physician may approve a refill that you may need at that time. If you are not a new patient and have an existing prescription, you may contact your pharmacy as needed to refill your prescription. You may need to contact your physician if all of your refills have been used. Your physician will determine if you need to continue the prescription at that time. If you want a new prescription you must see your primary care physician. You may be responsible for paying the pharmacy a co-payment for medications depending on your covered health plan benefits.
Yes, you may change your primary care physician by simply calling your health plan. With most health plans you must make the change prior to the 15th day of the current month for it to take effect on the first day of the following month.
A complaint is an expression of dissatisfaction with quality of care, quality of service, or issues regarding access to care. An example is not being able to get a timely appointment with your physician. If you wish to file a formal grievance, please call the member services department at your health plan at the number listed on your health plan membership identification card. Your health plan will contact Arta Health Network and work with us to resolve your complaint. If you are not satisfied with the outcome of your complaint, you have a right to complain to the Department of Managed Health Care (DMHC), which is responsible for regulating health care service plans, at their toll-free telephone number: 1-888-466-2219. The hearing- and speech-impaired may use the California relay service's toll-free telephone number 1-877-688-9891 (TDD) to contact the DMHC. The DMHC’s web site (www.hmohelp.ca.gov) has complaint forms and instructions online. For Medicare Advantage Prescription Drug (MAPD) and Special Needs Plan (SNP) members, a resource to assist you is the Medicare Rights Center, at 1-888-HMO-9050 and the Centers for Medicare and Medicaid at 1-800-MEDICARE. The hearing- and speech- impaired may use TTY/TTD: 1-877-486-2048. Of course, you can always contact AHN’s Customer Service Representative at 1-800-780-8879, Monday through Friday from 8:00 AM to 4:30 PM, to assist you with any grievance or complaint you may have.
You may appeal a denial of either an authorization or a claim for requested services ordered by your physician. If for example, your physician requests authorization for an outpatient surgery and the request is denied, you can have this denial reconsidered by your health plan by filing a formal appeal. In order to do so, you need to call the member services number on your health plan membership identification card. If you are not satisfied with the outcome of your appeal, you have a right to complain to the Department of Managed Health Care (DMHC), which is responsible for regulating health care service plans, at their toll-free telephone number: 1-888-466-2219. The hearing- and speech-impaired may use the California relay service's toll-free telephone number: 1-877-688-9891 (TDD) to contact the DMHC. The DMHC’s web site (www.hmohelp.ca.gov) has complaint forms and instructions online. For Medicare Advantage and Special-Needs Plan members, a resource to assist you is the Medicare Rights Center, at 1-888-HMO-9050 and the Centers for Medicare and Medicaid at 1-800-MEDICARE. The hearing- and speech-impaired may use TTY/TTD: 1-877-486-2048.
Call your health plan directly to file an appeal or a grievance.
Most pediatricians treat children up to the age of 18, with some exceptions. To avoid having to change your teenager's PCP once he or she reaches that age, you may choose to establish a relationship with an adult PCP prior to your teenager turning 18.
We do not quote any benefit coverage or co-payment information. You will need to contact your health plan’s member services department at the number listed on your health plan membership identification card for this information.
You may contact your health plan directly with any questions you may have concerning the coverage of specific services.
Contact your health plan directly for the most accurate and up-to-date information regarding your eligibility for covered services.
31. What is a case manager?
Arta Health Network case managers are licensed nurses who are experienced in assisting a patient through a hospital stay. These nurses will work closely with your attending hospitalist-physicians in order to identify and meet any special needs you may have both during your hospitalization and at the time of your discharge. Your case manager will arrange for after-hospital needs that are covered by your insurance such as extended-care facilities, home-health assistance and medical equipment, and other services your physician may order. The case manager will also explain to you what services are covered by your insurance.
HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. This law was designed to create a national standard for the protection of individuals’ privacy and the security of their medical records and other personal health information.
These are legal documents that give your family or caretaker direction on how to manage your health care if you become incapable of making your own decisions, or if you want someone else to make those decisions for you now even though you are still capable.
Arta members have the right to considerate and respectful care; to information regarding their medical care and treatment; and to the confidentiality and privacy of their health information. Arta Health Network’s member rights and responsibilities can be found on AHN’s "Member Rights and Responsibilities" page contained in this website.
35. May I request copies of my medical records?
Yes. You may ask for a copy of your medical records from your physician. You may be asked to sign a release of medical records form prior to receiving your records.