Your primary care physician is concerned about your health and will make every effort to ensure you receive the medical care you need. When medically appropriate, your physician may refer you for medical services that are outside the scope of his or her practice.
If this occurs, PMGSJ and your health plan may require that your physician requests prior authorization before you are referred for specialty services. This referral authorization process assists your physician in determining eligibility, health plan benefits, panel doctors, participating hospitals, etc. It also assures that your claims are processed in a timely manner. If prior authorization is required for specialty services and you receive care without an authorization, you may be responsible for the fees incurred.
In order to obtain prior authorization, your physician will submit a referral request for specialty services to Physicians Medical Group of San Jose (PMGSJ) through its management company, EXCEL MSO. EXCEL MSO will process the request and notify you and your physician of its determination. A copy of the criteria and/or guidelines used in the authorization process is available upon request.
PMGSJ/Excel MSO authorization decisions are based only on medical necessity and appropriateness of care and services. There are no financial incentives or payments that encourage inappropriate denial of services.
Prior authorization is not required for medical emergencies. If you or a member of your family is having a life threatening medical emergency, call 911 or go to your nearest hospital emergency room. As soon as possible after a medical emergency, it is recommended that you advise your primary care physician so that he or she may coordinate your continued care. Your health plan may also require that you notify them of emergency care.
You may contact our Member Services Department at (408) 937-3642 (TDD/TTY 711) or toll-free at (833) 923-5676 if you have questions regarding the prior authorization process.