Healthwise

Putting your healthfirst.SM
Kaiser Permanente

Chapter 1

Using the Kaiser Permanente System

Getting the Care You Need

We are offering you the Kaiser Permanente Healthwise Handbook to assist you in becoming an active and informed partner in your health care, and to help you and your family stay healthy. When you or someone in your family has a medical problem, this Handbook is one source of information to help you determine what the cause of the problem might be, what you can do to treat it at home, and when to seek professional help. It also offers valuable information on preventive care, nutrition, stress reduction, and many other issues.

For those times when you or a family member need to seek professional care, we've included this chapter to help make it easier for you to understand how to obtain it.

Please note that Kaiser Permanente continues to grow and change in an effort to improve our services. As a result, some of the information in this chapter may change over time. To be sure you have the latest information on what services are available and how best to use them, please consult your facility's most current Health Care Directory and read Partners in Health, our quarterly magazine for members, both of which are mailed to you at home.

Your Health Care Directory is one of your most important resources to help you get care as a Kaiser Permanente member. It provides helpful information including:

Important Kaiser Permanente phone numbers, locations, and hours of operation, and

The names and phone numbers of Kaiser Permanente providers practicing at your medical center.

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Getting Care - continued

You will be mailed a copy of your local medical center's Directory each time it's updated. We urge you to keep your Directory with this Handbook for easy reference.

If you don't have a copy of your local Health Care Directory, please contact the New Member Line at 1 800 955 9940 and we will send you one.

Questions? Problems?
Suggestions?
We're Here to Help

If at any time you have any questions, problems, or suggestions, please let us know. We will do everything we can to assist you.

If your question or problem is related to services you receive at our medical facilities, please talk to your personal provider, the department manager, the nursing supervisor, or the physician chief of the service in question. They are the people most able to provide you with advice and assistance.

If you're unable to resolve your problem with your provider or a manager at the facility, or if you have any questions about our services, call Patient Assistance. The number is listed in your Health Care Directory.

If your questions relate to your Health Plan coverage or to your monthly billings, a Customer Service Representative is available at 1-800- 464 4000. This representative can also replace your Kaiser Permanente identi- fication card and assist in updating your Health Plan membership.

Our goal is to keep you both healthy and satisfied, so please let us know how we can help.

Your Personal Health Care Provider

Choosing Your Provider

When you become a Kaiser Permanente member, you can choose either a physician or nurse practitioner as your personal provider. As your personal provider gets to know you, he or she can serve you better. As you get to know your provider, you can develop a feeling of trust knowing that an experienced professional is familiar with you and your health care needs.

You'll find a complete listing of physicians and nurse practitioners and their phone numbers in your local Health Care Directory.

When you make your selection:

Adults may select a physician or nurse practitioner from the Department of Internal Medicine.

Many of our facilities also have Departments of Family Practice that often provide care for entire families, including gynecological services.

Women may also choose a physician or nurse practitioner from the Department of Obstetrics/Gynecology.

Choose a physician or nurse practitioner from our Department of Pediatrics to care for the medical needs of your children.

Using the Kaiser Permanente System

Check your local Health Care Directory for appropriate phone numbers and refer to page 13 in this Handbook for tips on how to find the right doctor.

How to Use the Advice Nurse

Our advice nurses are specially trained to help you with your health care needs by phone. They work closely with our physicians and nurse practitioners and can often provide you with the assistance or information you need over the phone. If, after talking with you, the advice nurse decides that you need to see your physician or nurse practitioner, he or she can make the appointment for you.

You can find the phone numbers for your Pediatric, Internal Medicine, Family Practice, and Ob/Gyn advice nurses in your local Health Care Directory.

Appointments

Making Appointments

There are two types of appointments: urgent and routine. When you are sick or injured, you may have an urgent care problem. An urgent care problem is one that requires medical attention within 48 hours but is not an emergency. Some examples of urgent care problems are high fever that lasts for three days, vomiting that is violent or lasts for more than 12 hours, mild to moderate pain, a sudden rash, severe ear pain, or acute back pain.

If you think you have an urgent medical problem, call your physician or nurse practitioner's office, or if you do not have a personal physician or nurse practitioner, call the advice nurse.

At other times, you may need a routine appointment. Routine appointments are for health care needs that aren't urgent, such as check-ups, follow-up care, or camp or school physicals. Try to call as far in advance as possible when making a routine appointment. Check the department listings in your medical center's Health Care Directory for routine appointment telephone numbers.

Tips for Making Appointments

The best times to call for an appointment are from 10 a.m. to 12 noon and from 2 p.m. to 4 p.m.

Mondays are the busiest days. You may want to call on other days if your call is not urgent.

Have your medical record number handy when you call.

If you are placed on hold - hang on. Someone will be available to help you as quickly as possible.

If your provider asks you to return for follow-up care within two to three months, it is generally easier to make the appointment before you leave the office.

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Appointments - continued

Registering for Appointments

To make your visit go more smoothly:

Please plan to arrive at your medical facility at least 15 minutes before your appointment, so you'll have time to park and register.

Let the receptionist know if this is your first visit or a visit for a new work-related injury. If it is, please allow a little extra time for registration.

Please present your Kaiser Permanente identification card when registering for your appointment. If you are a new member.and haven't yet received your card, bring the medical record number you were given when you made the appointment.

Canceling Appointments

If you can't keep an appointment and do not want to reschedule, or if you decide to cancel at a time when your facility is closed, please call our Cancellation Recorder. The telephone number is listed in your local Health Care Directory. It's available 24 hours a day, 365 days a year. When you call, you'll be asked to leave your medical record number as well as your daytime phone number.

If you wish to reschedule your appointment, call the Appointments number listed in your Health Care Directory, during regular business hours.

Urgent Care for Kaiser Permanente Senior Advantage Members

If you are a member of our Kaiser Permanente Senior Advantage Plan, urgent care obtained from non-Kaiser Permanente providers is covered only when it is obtained outside the service area and only when:

Care is required to prevent serious deterioration of your health;

The need for care results from an unforeseen illness or injury when you're temporarily away from the service area; and

Care cannot be delayed until you return to the service area.

What to Do in an Emergency

An emergency is any sudden, serious problem requiring medical attention within minutes to several hours.

Some problems are emergencies because they're potentially life- threatening, such as poisonings, gunshot wounds, or a sudden inability to breathe.
Other problems are emergencies because, if not treated promptly, they may become more serious. Examples are deep cuts and broken bones.

24-Hour Emergency Services

Emergency care is available 24 hours a day, 365 days a year in the Emer- gency Departments of our Kaiser Permanente hospitals. Medical offices do not offer emergency services.

Using the Kaiser Permanente System

Patients with the most urgent medical problems are treated first.

Medical need, rather than the time of arrival, dictates the order in which patients are seen.

An experienced emergency nurse screens patients and may direct those with less serious problems to another department.

If you have a medical problem that's not an emergency, we encourage you to schedule an urgent care appointment instead of coming to the Emergency Department. If you're unsure whether your problem is an emergency, you can call the appropriate advice nurse at your local medical facility (listed in your Health Care Directory), or review the information in Chapter 15 of this Handbook, "First Aid and Emergencies," beginning on page 205, to help you decide.

Emergency Care for Kaiser Permanente Senior Advantage Members

Emergency care obtained by Kaiser Permanente Senior Advantage members from non-Kaiser Permanente providers both inside and outside the service area is covered only when:

Care is needed immediately because of a sudden injury or illness;

The time required to reach a Kaiser Permanente facility would mean risk of permanent damage to your health; and

Transfer to a Kaiser Permanente facility is precluded because of serious risk to your health, or is unreasonable due to the distance involved and the nature of your condition.

Ambulance Services

If you have a life-threatening condition or other p~vblem that requires an ambulance, call 911.

If you aren't sure how serious your problem is, or whether you need an ambulance, call the advice nurse for assessment.

Kaiser Permanente covers the cost of an ambulance only when:

The transportation is medically necessary; or
A Kaiser Permanente physician or other authorized staff member orders an ambulance or instructs you to call 911.

If you order an ambulance without authorization from Kaiser Permanente, and it's later determined that it was not reasonable to believe that an ambulance was medically necessary under the circumstances at the time of the call, you'll be billed for this service. For example, if you have severe chest pain and fear you may be having a heart attack, it's appropriate to call 911 for an ambulance. Kaiser Permanente would cover the cost of the ambulance service - even if it was found later that you did not suffer a heart attack - because it was reasonable to request an ambulance under the circumstances.

Health Education

As part of our commitment to helping you stay healthy, Kaiser Permanente offers a wide range of health education services. Your local Health Education Department is available to provide you with support, information, and skills to help you become an active, confident partner in your health care.

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Health Education - continued

Kaiser Permanente Health Education Centers are a convenient source of information. Here you can view health-related videos; find easy-to-understand pamphlets, magazines, and books; or choose from among a variety of free take-home literature and resource guides.

We also urge you to take advantage of the many Health Education programs and classes available throughout the year. You can learn more about specific health-related topics, such as diabetes, pregnancy and childbirth, heart disease, respiratory disease, AIDS, staying healthy, and many more. Current classes are listed in Partners in Health, our quarterly magazine for members.

To learn more about our Health Education services, call your local Health Education Department or ask your physician or nurse practitioner for information.

Pharmacy Services

Your local Kaiser Permanente pharmacy provides a variety of services, including:

Filling new prescriptions

Transferring prescriptions from another pharmacy

Providing refills

Consulting about your new medications.

For your convenience, our pharmacies also carry some common non-prescription medications and medical supplies. For pharmacy hours and locations, please check your Health Care Directory.

Prescription Refills

If you need to order a refill of your prescription, the most convenient way to do it is to call the 24-hour Refill Recorder at the medical facility where you'd like to pick up your prescription. The number is listed in your Health Care Directory. Be sure to leave your name, medical record number, daytime phone number, and prescription number on the recorder.

To help us help you more efficiently, please:

Try to make your refill requests at least 24 hours before you plan to pick up your medication.

Bring your prescription container with you when you pick up your refill.

If you need a prescription refilled but have "O" or "no refills remaining" indicated on the label, call your medical facility's Zero-Reffll Recorder (listed in your Health Care Directory). It's important for you to call several days before you run out of the medication. If your physician approves the refill, it will be ready for you within 72 hours.

Your Kaiser Permanente Identification Card

When you become a Kaiser Permanente member, we'll send you and each of your enrolled family members a personal ID card. This card is your "passport" to the health care benefits and services covered by your Health Plan.

Your Kaiser ID card contains important information that helps us serve you more eff~ciently. Please have your card handy when:

Calling for an appointment or medical advice
Visiting one of our medical offices for an appointment
Being admitted to one of our hospitals
Obtaining services from laboratory, radiology, EKG, pharmacy, or other departments
Talking with Member Services or Patient Assistance/Relations representatives
Traveling, in case you need medical care at any of our other facilities in Northern California or in any of our 11 other regions in the United States
You're hospitalized in a non-Kaiser hospital. Your ID card has the information you'll need when you notify Kaiser Permanente of your hospitalization.

Once your coverage becomes effective, you're eligible to obtain services at any of our medical facilities - even if you haven't yet received your card. If you'd like a temporary identification card, please call your local Member Services Department. If you lose your card, your local facility's Member Services Department will be happy to order a replacement card for you.

Advance Directives

Advance directives are documents that permit patients to state in writing their wishes about medical care or to designate someone to make those decisions in the event that the patient is unable to do so. Kaiser Permanente encourages all adults to complete an advance directive form called the Durable Power of Attorney for Health Care. For more information about advance directives or how to complete them, please call your local Health Education Department (listed in your Health Care Directory).

Healthwise Handbook

Receiving Care Outside the Kaiser Permanente System

You are expected to use Kaiser Permanente for all your medical care unless you are part of one of our special programs which contain certain exceptions. Non-emergency medical care obtained outside our Kaiser Permanente medical facilities will be covered only if it was obtained under the direction of your personal physician and after a written and approved authorization for outside medical care is issued.

If You Are Admitted to a Non-Kaiser Hospital

If you are admitted to a non-Kaiser hospital, you must telephone Kaiser Permanente within 24 hours or as soon as reasonably possible, so that we can oversee your care and determine when you're able to travel or be transferred. (An exception is in Stockton, where Kaiser Permanente members go to Dameron Hospital for their hospital needs.) The toll-free phone numbers to call are listed here and on your Kaiser Permanente identification card.

In California . . . 1-800-772-3532

Other States . . . 1-800-227-2415

Your Health Plan coverage includes an emergency services benefit that provides for payment by Kaiser Permanente of the reasonable cost of medically necessary health services that are immediately required because of unforeseen illness or injury, as determined by Kaiser Permanente. However, if the services are obtained from non-Kaiser Permanente providers within the service area, your benefit provides for payment only if the delay in reaching a Kaiser Permanente facility would have resulted in death, serious disability, or significant jeopardy to your condition.

Coverage for emergency services continues only until your condition permits travel or transfer to the nearest Kaiser Permanente facility. Continuing or follow-up care by the non-Kaiser Permanente providers is not covered. For more information, consult your Disclosure Form and Evidence of Coverage.

Submitting Claim Forms

To request payment for any emergency services you receive from a non-Kaiser Permanente provider, you must submit a claim form.

Claim forms should be sent to:

Kaiser Permanente Claims Department P.O. Box 12923 Oakland, CA 94604-29230

For more information on this benefit or on how to obtain or submit a claim form, please call your local Health Plan Office (listed in your Health Care Directory).