When should I call my health plan and when should I call PMGSJ?
Call your Health Plan for:
- Hospital/facility issues or bills
- Changing your Primary Care Physician
- Questions about benefits, copays
Call PMGSJ Member Services (408-937-3600) for:
- Doctor issues, bills
- Help getting the care you need
- Help choosing a physician
- Check on a referral authorization
- General questions
What hospitals can I go to?
In an emergency, go to the nearest hospital. PMGSJ has affiliations with Good Samaritan Hospital, El Camino Hospital – Los Gatos, El Camino Hospital – Mountain View, Lucile Packard Childrens Hospital, O’Connor Hospital, Regional Medical Center, St. Louise Hospital, Stanford Hospital, and Santa Clara Valley Medical Center.
If I change Primary Care Physicians, are my specialist authorizations still valid?
If your change involves a new Medical Group, you will need new referrals and may have to change to a new specialist within your group. If you have changed Primary Care Physicians within Physicians Medical Group, your referrals are still valid, but please let your specialists know of the change, and advise your new Primary Care Physician of any specialist care you are receiving.
If I get a bill for medical services, what should I do?
First, make sure that the biller has your insurance information, including the address for Physicians Medical Group. If they do, and you are still being charged, call PMGSJ Member Services or write your phone number on a copy of the bill and mail to PMGSJ, PO Box 641506, San Jose, CA 95164-1506 Attn: Member Services. Don’t ignore the bill!
If my authorization is expiring, can I get an extension?
Yes. The physician that requested the authorization or the Specialist you are seeing can ask for an extension, or you can call PMGSJ’s Member Services.
What does a medical group do?
A Medical Group or IPA is a network of physicians. At PMGSJ we have over 1000 primary care and specialist physicians, as well as ancillary care providers. The network contracts with your health plan to provide your care, and is assigned to you based on which Primary Care Physician you have.
You must seek all of your non-emergency care within your medical group, (for instance, the OB/Gyn or Radiologist you see must be within your group), so it is important to know which medical group each family member has been assigned. Check your family’s ID cards.
Your medical group manages your provider network, verifies the credentials of your physicians and continues to review their quality performance, sets up the processes for referral and authorization, and does the verification of benefits and appropriateness of care when you are referred to a specialist or for a procedure.
It is our goal to keep your medical care as uncomplicated as possible, so if you have questions or need some assistance, call us first.
What is “Urgent care?”
Urgent care is defined as medical conditions, illnesses, and injuries that are not life-threatening or serious but require prompt medical attention. Urgent Care provides you reasonable immediate access to medical care for a wide range of conditions from minor injuries and illnesses.
What to do if you need urgent or after-hours care:
- Call your Primary Care Physician. If you cannot reach your doctor, you can call your health plan's 24-hour health advise and concern line, if available. Look on your membership card for available phone numbers.
- If you have a medical problem that requires attention, use one of PMGSJ’s Urgent Care Centers. Refer to our After Hours and Urgent Care listing for additional information. Click Here for List
Can I go to emergency care or urgent care when I am away from home?
Yes, and call your health plan as soon as possible to tell them you are going to a hospital emergency or urgent care facility.
What do I do in an emergency?
Call 911 or go to your nearest hospital or urgent care facility. Emergency Care is appropriate when the absence of immediate medical attention can reasonably be expected to result in placing your health in immediate jeopardy, serious impairment to bodily functions, or other serious medical consequences. IMPORTANT: Follow up care must be provided in network, through your Primary Care Physician. Routine or elective services provided in an Emergency Room or Urgent Care Center are not covered.
What do I do if my Primary Care Physician cannot see me?
If you call your Primary Care Physician and the recording answers, listen all the way through the recording. Your doctor may name another who is seeing patients in his/her absence. If the office staff answers, ask them to refer you to another doctor that is seeing his/her patients in his/her absence. If you are still unsuccessful in finding a physician, call PMGSJ’s Member Services to ask for the name of a doctor that may be available to see you.
Can I choose a different Primary Care Physician for each member of my family?
Yes. Please note that other family members may belong to a different medical group, so be sure to present the correct card when seeking care.
Can I change my Primary Care Physician?
You are welcome to change your Primary Care Physician at any time.
Why do I need a Primary Care Physician?
If you are member of an HMO, your Primary Care Physician is the first person you call for all your healthcare needs, except for obstetrics and gynecology. Your Primary Care Physician will refer you to a specialist when the need arises.
How do I find a Primary Care Physician?
When you receive your new healthcare card, your insurance carrier will have assigned you to a physician. If you prefer to select a physician yourself, you may call Member Services at PMGSJ to request or go to our provider directory of all our doctors. Adults may choose from GP (General Practice), FP (Family Practice), or IM (Internal Medicine). Children may be assigned to a Pediatrician, FP or GP. To make the change, call your health plan Member Services at the 800 number on your card.