FAQs

Alta Bates Medical Group is an Independent Practice Association (IPA). An IPA is an organization of independent physicians that have joined together to contract with HMOs and other health care companies for the provision of professional medical services. Physicians belonging to an IPA usually have their own offices, separate from other physicians in the IPA.

ABMG was formed in 1983 by physicians in the Berkeley area affiliated with Alta Bates Hospital. Today, ABMG has over 200 primary care physicians and 400 specialist physicians in the East Bay and provides services at the Berkeley and Oakland campuses of Alta Bates Summit Medical Center.

2. What Hospitals Does ABMG Use?

Alta Bates Medical Group is contracted with Alta Bates Summit Medical Center with campuses in Berkeley and Oakland as well as Children’s Hospital Oakland for pediatric inpatient services.

3. Does ABMG Accept Your Insurance?

Alta Bates Medical Group is contracted with the following health maintenance organizations:

Aetna
Blue Cross CaliforniaCare
Blue Shield
Cigna
Health Net
PacifiCare

Additionally, we contract with Health Net Seniority Plus and PacifiCare Secure Horizons for Medicare members.

4. What is a Primary Care Physician (PCP)?

A PCP is the doctor you select to be your personal physician. As a member of ABMG, your Primary Care Physician (PCP) works with you to make decisions about your care and to recommend specialists when medically appropriate. Your PCP plays many roles - primary caregiver, health care advisor, coordinator of specialty care and patient advocate. PCPs can include:

Family/General Practitioners (Doctors who treat patients of all ages)
Internists (Doctors who treat adults and may have a subspecialty)
Pediatricians (Doctors who treat children)

To choose a PCP within ABMG, please contact Customer Service at 866.681.0737. They can help you find the right doctor and answer questions about a physician's education, specialty, sub-specialty, office locations, hours, and languages spoken.

5. Can my OB/GYN be my PCP?

No. ABMG OB/GYN physicians provide specialty care services rather than primary care services. Since you cannot select your OB/GYN as your PCP at ABMG, you do not need a referral from your PCP to see an in-network OB/GYN. Ask your PCP which doctors are available to you, or call customer service at 866.681.0737.

back to top
6. What is a specialist?: A specialist is a physician that focuses on one area of medicine. From allergy to vascular surgery, a specialist is trained as an expert in his/her particular field. In many cases, your PCP will refer you to, and work with, a specialist to ensure you receive proper medical attention and follow up care.

back to top
7. What is a referral?: When your PCP wants you to see a participating specialist, they will fill out a referral form. Your PCP will either mail the referral to the specialist or you can bring it to your first appointment.

8. When can I see a specialist without a referral?

Female members may self-refer to ABMG obstetricians-gynecologists for all OB/GYN related services. Members can also self-refer to a behavioral health provider by using the number on their health plan cards or by calling Customer Services at 866.681.0737.

9. What is an authorization?

In some cases, ABMG requires an authorization for specialist care in order to determine if the requested service meets certain criteria (medical necessity, benefit coverage). Authorization requests are initiated by your PCP and typically processed within 14 days, except in urgent situations, and you will be notified by mail when the authorization has been processed. To check on the status of an authorization, or if you have not received notification after 14 days, please contact Customer Service at 866.681.0737. The authorization is valid for up to 180 days from date issued and there is no limit to the number of visits with the specialist.

back to top
10. My authorization was denied. How can I appeal?: The first step to appeal a denied authorization is for you to contact your health plan. To do this, you will need the authorization number. If you do not have the authorization number, please contact Customer Service at 866.681.0737.

back to top
11. What is the enrollment process?: Your health plan provides us your eligibility and benefit information after they receive it from your employer. While this enrollment process can take up to 90 days, please be assured that your benefits are effective from your date of eligibility.

back to top
12. How do I change my enrollment information?: Your health plan is responsible for updating your personal and benefit information. You must contact your employer or health plan directly. Your health plan will notify ABMG with any changes.

back to top
13. My company changed health care insurers. Can I keep my current physician?: Because ABMG is contracted with several health plans, you may be able to maintain your relationship with your physician even when it is necessary to change your health plan. Please contact our Customer Service at 866.681.0737 as soon as you learn your company is switching plans.
14. I got a bill for my doctor's visit saying I didn't have coverage. It appears that my old Health Plan was billed; what do I do?: Please contact our Customer Service at 866.681.0737. We will then make the necessary changes to your account and rebill the correct insurance plan.

15. Who should I call for...?

Call your PCP office for:

Medical problems
Appointments
Referrals to specialists

Call your health plan for:

Prescription drug and other benefit coverage information
To change your PCP or your address. Once they have updated your enrollment record, they will provide that information to us.
To obtain an insurance ID card
To obtain information about your premiums

Call Alta Bates Medical Group (866.681.0737) for:

Assistance with billing problems

16. What do I do in case of an Emergency?

An Emergency is a sudden illness or injury, such as a chest pain or uncontrolled bleeding. In cases of life-threatening emergency, go to the nearest emergency room or call 911.

For all other urgent care matters, there is a doctor on call at your physician's office 24 hours every day. The on-call doctor will advise you what to do next. After any health crisis, it is important that you call your physician's office, within 48 hours if possible, so that your doctor can be involved in your care.

17. What health education classes are available?

Alta Bates Summit Medical Center offers a variety of health education and health promotion classes, many of which are free and open to all ABMG members. Call (510) 204-4444 or visit http://altabatessummit.org/health/ for detailed information.

18. I am receiving a bill for services that I thought were covered. Who do I contact?

Please contact the company from whom you received the bill to ask why you are receiving it. The bill may be for your copay, deductible, or a non-covered service.

back to top
19. I received a letter from ABMG asking me about a visit to my doctor. It is asking me whether or not my visit was related to an accident. I have not been involved in an accident, what should I do?: Often medical treatment related to an accident is covered by the auto insurance of another party. We simply need to know if your medical expenses should be billed to another insurance company. Please answer the questions appropriately and mail the questionnaire back to us.

back to top
20. How do I appeal a medical review request that has been denied?: You must appeal any denial determination directly to your health plan. All appeal information is included in the denial notice sent to you and your physician.

back to top
21. Who do I call to make a complaint?: Complaints may be submitted to Customer Service at 866.681.0737, or to your Health Plan using the number on the back of your Health Plan ID card.

Alta Bates Medical Group

FAQs

ABMG News

Healthcare News