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All members have the right to appeal any Monarch Healthcare decision. All appeals must proceed through the members contracted health plan.

Appeals:

Written or verbal requests to reconsider the initial determination of a denied healthcare service or claim.

A member may request an appeal by:

  • Written or Verbal notification to their Health plan representative to appeal any decision they feel is unfair or unjust. 
  • Written or Verbal notification to the Monarch healthcare Contracted provider (Physician) to appeal a decision.
  • Fax, Written or Verbal notification of an appeal through the Customer Service Department  of Monarch HealthCare at (888) 767-2222. All verbal, written or faxed appeals will be directed to the member’s specific health Plan.

Grievances:

Complaint or inquiry - A member’s written or verbal request for information, assistance or concern with an issue. A complaint can become a grievance.
Grievance – The written or verbal expression of a member’s dissatisfaction with the care or services provided, and may be utilized to request review of a complaint/issue that has not been resolved to the member’s satisfaction.

  • The member submits a complaint or grievance to the Customer Service  Department of Monarch HealthCare at (888) 767-2222 or the member’s specific Health Plan either verbally or in writing. If given to Monarch Healthcare, the complaint or grievance will be forwarded to the member’s health plan as well as be reviewed for quality of care or quality of service issues by the Quality Management Specialist who will then work on a resolution of the issue.

 

Senior and Disabled Persons Transportation Resources

Senior Non-Emergency Medical Transportation Programs - ($2.00 per ride)

  • North County Senior Connections Program: (714) 446-7151
    Serving Anaheim, Anaheim Hills, Brea, Buena Park, El Modena, Fullerton, La Habra, La Palma, Orange, Placentia, Villa Park, and Yorba Linda
  • South County Senior Transportation Services:(949) 855-9766
    Serving all cities near and around Aliso Viejo, Irvine, Laguna Beach, Laguna Woods, Mission Viejo, Newport Beach, San Juan Capistrano and Rancho Santa Margarita
  • St. Anselm’s Senior Non-Emergency Medical Transportation:(877) 777-0988
    Serving all cities near and around Costa Mesa, Cypress, Fountain Valley, Garden Grove, Huntington Beach, La Palma, Los Alamitos, Orange, Midway City, Seal Beach, Stanton, Tustin, and Westminster

Orange County Transit Authority (OCTA) bus schedule: (800) 636-7433

OCTA ACCESS   Program for disabled persons: (877) 628-2232
Curb-to-curb ($2.25) or door-to-door ($4.50) per trip
Service for all purposes and for all ages, but client must meet disability criteria

Senior Dial-A-Taxi Service(for Mission Viejo residents only)
Door-to-door service for non-medical purposes. $5.00 per one-way trip, or $10.00 for round-trip.  For additional information, call the Mission Viejo Recreation and Community Services Department at (949) 470-3061.

All of these and other senior services can be accessed by calling the County of Orange Office on Aging at: (800) 510-2020.

 

An emergency is any situation that places a person’s health in serious jeopardy.

Emergency situations include:

  • Unconsciousness
  • Symptoms of a heart attack, such as chest pain, shortness of breath, nausea, sweating
  • Severe breathing problems
  • Severe, uncontrolled bleeding
  • Symptoms of shock, such as pale, clammy skin, weakness, rapid heart rate
  • Possible spinal, neck or head injury

Specific examples of emergencies:

-Any symptoms of an allergic reaction following a bite; extreme breathing difficulty, constriction in the chest, swelling of the mouth, lips, tongue or throat, severe hives and itching or violent coughing

-If you are bitten by a black widow or brown recluse spider or known poisonous insect

-Snake bite the breaks the skin

-Puncture wounds where bleeding is steady, profuse, or occurs in rhythmic spurts

-Signs of shock including: weakness; confusion; cold, pale, moist skin

-Open wounds that are deep and penetrates to muscle or bone

-An embedded object, such as a knife

- A head/spinal injury where:
A seizure or loss of consciousness occurred
Loss of bowel or bladder control
Visual changes occur or pupils are fixed or unequal
You have difficulty walking or speaking
Change in mental status such as (confusion, disorientation, extreme drowsiness or lack of   responsiveness)
An infant has a budging soft spot or cries for more then 15 minutes

- Broken Bones where:
The limb is cold, blue or numb
The pelvis or thigh is injured
Signs of shock (cool, clammy, pale skin, dizziness, light-headedness or thirst)
Bone protrudes through the skin
The injured part is crooked or deformed
Heavy bleeding occurs or blood spurts out

- Infected Wounds when:
Redness around the area has streaks leading away from it
Pus
Fever of 101F or higher
Tender or swollen lymph nodes

- A headache where there is:
Sudden confusion, trouble talking
Sudden trouble seeing in one or both eyes
Trouble walking or loss of balance
Sudden/severe headache without cause

-Complete loss of consciousness

- An infant younger than 3 months has a rectal temperature of 100.4F (38C) or higher, even if the temperature becomes normal.

- A Cough when there is significant respiratory distress, such as:
A feeling of suffocation
Gasping or straining to get a breath
Bluish color to the lips or skin

- A Nosebleed and:
You are on an anticoagulant, taking aspirin frequently or have a bleeding disorder
Blood flows heavily down the back of your throat
Bleeding is heavy and lasts more then 30 minutes

- Palpitations and:
Shortness of breath
Crushing, squeezing or increasing pressure in the chest
Fainting
Confusion

- High Blood pressure and your Systolic pressure is 210 or 120 Diastolic and you have any of the following:
Headache
Visual changes
Nausea
Drowsiness or confusion

-Chest pain and:
Crushing, squeezing or increasing pressure in your chest

Chest, jaw, neck, shoulder or arm discomfort occurs with:
SOB
Confusion, dizziness, weakness or fain feeling
Nausea or vomiting
Rapid, irregular pulse

- Asthma and:
Severe symptoms of respiratory distress
Chest pain
Out of control attack

Ref:  Care Wise Guide- Self Care from Head to Toe, Care Wise Inc, Seattle Washington

You and your health come first with Monarch HealthCare. Monarch is committed to providing the best quality of care and services to help you stay healthy. With one of the highest Patient Satisfaction ratings in all of Orange County* and ranking state-wide in the top 20th percentile, you can feel confident as a member of Monarch HealthCare that you will receive the highest quality healthcare service.

In addition to our achievements in satisfaction, Monarch HealthCare also has the distinction of being recognized repeatedly in the industry for investment in Information Technology and our ability to integrate data in a comprehensive way that allows our physicians to make informed decisions regarding your care.

Every year, we develop strategic clinical and service goals to help us improve your overall health and healthcare experience.  One important component of maintaining good health is receiving periodic health screenings and making sure you are being appropriately managed if you have a chronic condition.

Our Clinical goals are to improve the health of our members in the following key areas:

    • Ensure members receive the following early detection and preventive health screenings:

      • Breast Cancer Screening
      • Cervical Cancer Screening
      • Chlamydia Screening
      • Colorectal Screening
    • Improve outcomes in members receiving care for the following chronic conditions:

      • Diabetes
      • Cardiovascular Conditions
      • Heart Failure

Our Patient Satisfaction goals are to improve the quality of service you receive in the following areas:

      • Patient-Doctor Communication
      • Care received from Specialist
      • Timely Access to Care
      • Coordination of Care

We monitor our progress at least annually through several independent reports on quality of care that compare our results against other physician organizations.

* http://opa.ca.gov/report_card/medicalgrouprating.aspx

Monarch HealthCare encourages their members to take an active responsibility in making informed decisions about their health care through the Advance Health Care Directive Program. The Advance Health Care Directive is a document that gives you the opportunity to name another individual (family member or close friend, etc.) to make health care decisions for you in the event that you are unable to do so, or if you want to name someone to make health care decisions for you, even if you are still capable.  The Advance Health Care Directive also allows the physician to know your wishes concerning health care decisions made on your behalf.  You may place limits on the authority you give to the individual you appoint to make health care decisions for you.

Advanced Health Care Directives FAQ

Why should I fill out an Advance Directive?
If you should become unable to make your own healthcare decisions, Advance Health Care Directives allow you to appoint someone (your agent) to make your healthcare decisions if you are unable and to express your wishes about end of life care

What does the Advance Directive do?
Allows you to appoint someone as your agent to make health care decisions on your behalf should you be unable to do so.  Allows you to express your wishes now to limit future care if:

  • You have an incurable, irreversible condition for which death is expected in a short time
  • You are unconscious and will probably not regain consciousness
  • The risks and burdens of treatment outweigh the expected benefits
  • Allows you to direct alleviation of pain even if it hastens death
  • Allows you to write out other health care wishes

Do I have to fill out an Advance Directive?
No. Advanced Directives are not mandatory.  They are your choice.

What if I do not fill out an advance directive?
You continue to make your health care decisions.  If you are unable to make your own decisions, your physicians will attempt to care for you as best they can.  Health care decisions will usually be made in consultation with family members or significant others.

Does the advance directive affect my medical treatment now?
No. Advance Directive does not affect your treatment in any way other than as expressed in the document

How long is this advance directive valid?
Advance Directive is valid indefinitely unless you specify an expiration date or revoke it

Can anyone fill out an advance directive?
You need to be at least 18 years old (or an emancipated minor), mentally competent, and acting of your own free will to complete an Advance Directive

Further information can be obtained from Monarch HealthCare’s Customer Service at (888) 767-2222.

You can also visithttp://www.ag.ca.gov/consumers/general/adv_hc_dir.htm.

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