1. What is Brown & Toland?
Brown & Toland Physicians is an independent practice association of community physicians in San Francisco. Brown & Toland physicians provide the highest quality, comprehensive care to the patients they serve.

Brown & Toland was established in 1992 as California Pacific Medical Group and expanded in 1997 to create Brown & Toland Physicians. With more than 800 physicians accepting multiple insurance products including HMOs (Health Maintenance Organization) and PPOs (Preferred Provider Organization), Brown & Toland is a premier physician group in the state.

2. What is the difference between an HMO and a PPO?
The primary difference between an HMO and a PPO is that the HMO product requires that, in most instances, you obtain a referral when seeking specialty care. Unlike other medical groups, Brown & Toland allows you to see a specialist with a referral from your PCP rather than from the medical group or health plan. For certain specialties, no referral is required.
A PPO allows you to direct your own specialty care within a contracted network of physicians, or a non-contracted physician at a higher out of pocket cost. All Brown & Toland physicians accept HMO insurance and most accept PPO insurance as well.

3. How do I choose a Primary Care Physician (PCP)?
If you have HMO insurance, you need to choose a PCP who is responsible for coordinating all of your healthcare needs, including referrals for specialty care and hospital care. You may visit our online physician directory or speak to our Customer Service Department at 1.800.225.5637 to learn more about a physician's education, specialty, or location. You may also download and print a complete listing of our physicians. To officially designate a PCP and receive an ID card with your PCP selection, you must contact your health plan's member services department directly (see health plan member services link).

4. What's the difference between a referral and an authorization (HMO only)?
A referral is a written directive from your physician to another in-network Brown & Toland provider. In most cases, the written referral is good for up to six months from the date of issue.

An authorization is a request for service that requires formal review by Brown & Toland. Before many types of specialized services are provided, such as a non-emergent hospital admission, surgery, durable medical equipment, infusions and certain tests, benefit coverage, member eligibility, and medical necessity are reviewed by Brown & Toland on behalf of your HMO. Your physician is familiar with this process and will request prior authorization from Brown & Toland when necessary. Brown & Toland reviews these requests and responds to your physician quickly. You will receive a formal letter detailing the outcome of our decision along with specific valid to and from dates. It should be noted that an authorization is not a guarantee of payment. You must be eligible on the date of service.

5. When may I see a Brown & Toland specialist without a referral?
The following do not require a referral from the PCP if provided within the Brown & Toland HMO network:

Women may self-refer to a Brown & Toland obstetrician/gynecologist.

Women may self-refer to Brown & Toland facilities for annual mammogram screenings.

Patients may be referred to Brown & Toland podiatrists and ophthalmologists with only a verbal approval from their PCP.

PPO members may self refer for any specialty care within the Brown & Toland PPO physician network.

6. May I request services using "out-of-network" providers or facilities?
Brown & Toland has quality "in-network" providers and facilities for all services. In the event that a particular service is not available in-network, your provider will request prior authorization from Brown & Toland to use "out-of-network" services. Unless provided in an emergency situation, "out-of-network" services will generally not be covered unless pre-approved. Our goal is to ensure you receive high-quality care from excellent providers in a timely manner.

7. How do I change my (enrollment) information?
Changing your address or adding a dependent must be coordinated through your health plan directly. Brown & Toland is electronically linked to all of our health plans and they transmit your enrollment information to us on a regular basis. In some cases, especially with large employer groups, you simply need to notify your employer, who in turn electronically notifies your health plan. This information is then transmitted electronically to Brown & Toland.

8. With which HMO health plans does Brown & Toland Medical Group physicians contract?
Aetna, Blue Cross, Blue Shield, CIGNA, Great West Healthcare, Health Net, and PacifiCare.

9. Which hospitals are part of the Brown & Toland Medical Group network?
California Pacific Medical Center (CPMC)-Pacific, California, Davies & St. Luke's campuses, Saint Francis Memorial Hospital, St. Mary's Medical Center , Chinese Hospital, Seton Medical Center in Daly City, and Seton Coastside in Moss Beach.

10. What is the difference between Emergency and Urgent Care services?
Emergency Services are required as a result of unforeseen injury or acute illness for which delay in treatment would result in a permanent physical impairment or loss of life. Chest pains or excessive bleeding may be an example of Emergency Services.

The term emergency medical condition means manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person with an average knowledge of health and medicine, should reasonable expect the absence of immediate medical or psychiatric attention to result in: 1) serious jeopardy to the health of the individual (or unborn child); 2) serious impairment to bodily functions; or 3) serious dysfunction of an bodily organ or part.

Urgent Care is defined as those services required as a result of unforeseen injury or acute illness that requires immediate attention, for which delay in treatment would NOT result in a permanent physical impairment or loss of life.

11. When is it appropriate to seek Emergency Room treatment?
If you experience a life threatening injury or sudden illness for which delay in treatment would result in permanent physical impairment or loss of life, you should immediately call 911 or go to the Emergency Room. Chest pains, excessive bleeding and broken bones would be situations where your condition would warrant emergency room treatment. In all other scenarios, contact your PCP who has coverage 24 hours a day/seven days a week, and describe your symptoms. You will be directed to the appropriate level of care.

12. What is the difference between a family physician and an internist?
A family physician treats both adults and children. Family physicians are trained in dealing with family issues and relationships, and may provide general gynecology services.

An internist treats mostly adults 18 and above and specializes in the diagnosis and treatment of disease.

13. Should my teenager see a pediatrician?
Most pediatricians treat children up to the age of 18, with some exceptions. To avoid having to change the teenager's PCP once he or she reaches that age, you may choose to establish a relationship with an adult PCP prior to your teenager turning 18.

14. If I am not satisfied with the care I am receiving from my physician, how do I file a grievance or complaint?
A complaint is an expression of dissatisfaction with quality of care, quality of service, or issues around access to care. An example is not being able to get a timely appointment with your physician. If you wish to file a formal grievance, please call the Member Services Department at your health plan. You can find their number on the back of your health plan enrollment card. Your health plan will contact Brown & Toland and work with Brown & Toland to resolve your complaint. If you are not satisfied with the outcome of your complaint, you have a right to complain to the Department of Managed Health Care, which is responsible for regulating healthcare service plans, at their toll-free telephone number 888.466.2219. The hearing- and speech-impaired may use the California relay service's toll-free telephone number 877.688.9891 (TDD) to contact the department. The department's Web site (www.hmohelp.ca.gov) has complaint forms and instructions online. For Medicare +Choice members, a resource to assist you is the Medicare Rights Center, at 888.HMO.9050 and Medicare at 800.MEDICARE. The hearing- and speech- impaired may use TTY/TTD: 877.486.2048.

15. If I disagree with a denial of either an authorization or a claim, how can I appeal the denial?
You may appeal a denial of either an authorization or a claim for requested services ordered by your physician. An example is your physician requests authorization for an outpatient surgery and the authorization request is denied. You can have this denial reconsidered by your health plan by filing a formal appeal. In order to do so, you need to call the Member Services number on the back of your health plan enrollment card. If you are not satisfied with the outcome of your appeal, you have a right to complain to the Department of Managed Health Care, which is responsible for regulating health-care service plans, at their toll-free telephone number 888.466.2219. The hearing- and speech-impaired may use the California relay service's toll-free telephone number 877.688.9891 (TDD) to contact the department. The department's Web site (www.hmohelp.ca.gov) has complaint forms and instructions online. For Medicare Advantage members, a resource to assist you is the Medicare Rights Center, at 888.HMO.9050 and Medicare at 800.MEDICARE. The hearing- and speech-impaired may use TTY/TTD: 877.486.2048.