FAQ for Patients

The term managed care describes a group of healthcare providers like Meritage who contract with health plans to provide a network of physicians and care for patients in a coordinated way.

Your Primary Care Physician is responsible for managing your care and referring you to any specialists that you need for your particular health situation. You and your primary care physician are equal partners in decision-making.

Your health plan will provide you with a list of primary care physicians who are accepting new patients for you to choose from. If you do not select one, your health plan will select one for you.

If you are switching from one Meritage health plan to another and wish to stay with your current primary care physician, please make sure to advise your health plan that you are an existing patient with that doctor who may be listed as closed to new patients.

Yes, a good relationship is key. We can help you find a doctor based on office hours & location, languages spoken, sensitivity to cultural considerations and other choices (all listed on our website here).

Once you’ve decided who you want your primary care physician to be contact your health plan to inform them of your desire to change your primary care physician. Your health plan will then notify Meritage of the change and you will be issued a new insurance card showing your new primary care physician and the effective date of the change. Please note, Meritage cannot change your primary care physician of record nor do we issue new insurance cards.

To find out if a doctor is part of the Meritage Medical Network, you can search our website by specialty, name, and location at www.meritagemed.com. On the homepage complete the information in the search area: “find a doctor.” Or you can call our customer service team at 415-884-1840, Option 2.

Yes, your primary care physician is trained to treat most medical conditions.

Referrals to Specialists:
Should you need to see a specialist, your primary care physician will refer you to the specialist who will address your specific healthcare need. You do not need a referral from your primary care physician for routine OB/GYN care.

Services that Require Prior Authorization:
Your primary care and/or specialist is responsible for submitting his/her own prior authorization request.

Your health plan contracts with Meritage to administer most of your medical benefits. When you enroll in an HMO plan and choose Meritage as your medical group, you are able to access our network of doctors and hospitals. MMN also processes all authorization requests and pays professional type claims (doctor’s appts, lab work, radiology, etc.)

If you have a medical emergency, please call 9-1-1. For all other after-hours inquiries, you can call your primary care physician’s office and ask to speak with the physician on call. You can also seek medical treatment at one of our in-network after-hours facilities and locations (link).

There are a few reasons why a claim would not be paid. The best place to start for this question is the provider’s office. You may also call the Meritage customer service team at 415-884-1840.

Meritage does not send bills to members. You will need to contact the physician or provider’s billing department to determine why you have received a bill and also verify that the office has your insurance information on file.

You may contact our customer service team at 415-884-1840, Option 2, for a review of any copayment you disagree with. If we cannot resolve this matter over the phone then you will need to contact your insurance plan and request a review.

Medicare Advantage is managed care for Medicare; Medicare beneficiaries may choose to purchase a Medicare Advantage product from a health plan which provides access to a network of physicians, providers, and facilities at fixed costs.

Meritage is currently contracted with these Medicare Advantage Plans within these counties:

• United Healthcare
• Health Net
• Aetna Medicare Solutions
• Alignment Health Plan
• Western Health Advantage

By selecting a Medicare Advantage plan with Meritage as your physician network, you will have access to:

• 700 primary care and specialist physicians in Marin, Sonoma, Napa, and Solano Counties.
• Local, dedicated customer service and administrative teams.
• Award winning care coordination services including Care Management, Behavioral Health and Care Transitions services to help you transition from Hospital to home should you need to go to the hospital.

Meritage has been providing care in NorCal for Over 40 years, to learn more, please visit our About Us page (link).

You will need to contact your insurance company to initiate the formal appeals and grievances process. Meritage is not delegated to handle member appeals. Members must contact their insurance company directly.

During your Annual Wellness Visit, you and your provider will create a prevention plan based on your needs.

The treating physician is responsible for submitting his/her own request. If your primary care physician has referred you to a specialist, that specialist is responsible for securing authorization for any subsequent services.

Referral to a Meritage member physician is valid as long as the specialist is actively treating the condition for which you were referred. Care ends once the treating physician discharges your care back to your PCP. If the physician is not a member physician, authorizations are generally valid for 3 months.

Your treating physician will know which service(s) require prior authorization. If authorization is required, the request will be submitted to Meritage and you will be notified of the outcome via mail.

Authorizations can take 5-14 days, but usually are quicker. Medically urgent requests are processed within 72 hours.

You do not need a referral from your primary care physician to see a Meritage OB/GYN. Please see a list of Meritage OB/GYNs here (link).

Prior authorization is required. Your treating physician will initiate the request on your behalf for all requests to out of network physicians, facilities, labs, etc.

Please contact our customer service team at 415-884-1840, or 800-874-0840.

There are a few reasons why a claim would not be paid. The best place to start for this question is the provider’s office. You may also call the Meritage customer service team at 415-884-1840.

Meritage does not send bills to members. You will need to contact the physician or provider’s billing department to determine why you have received a bill and also verify that the office has your insurance information on file.

You may contact our customer service team at 415-884-1840, Option 2, for a review of any copayment you disagree with. If we cannot resolve this matter over the phone then you will need to contact your insurance plan and request a review.

Medicare Advantage is managed care for Medicare; Medicare beneficiaries may choose to purchase a Medicare Advantage product from a health plan which provides access to a network of physicians, providers, and facilities at fixed costs.

Meritage is currently contracted with these Medicare Advantage Plans within these counties:

• United Healthcare
• Health Net
• Aetna Medicare Solutions
• Alignment Health Plan
• Western Health Advantage

By selecting a Medicare Advantage plan with Meritage as your physician network, you will have access to:

• 700 primary care and specialist physicians in Marin, Sonoma, Napa, and Solano Counties.
• Local, dedicated customer service and administrative teams.
• Award winning care coordination services including Care Management, Behavioral Health and Care Transitions services to help you transition from Hospital to home should you need to go to the hospital.

Meritage has been providing care in NorCal for Over 40 years, to learn more, please visit our About Us page (link).

You will need to contact your insurance company to initiate the formal appeals and grievances process. Meritage is not delegated to handle member appeals. Members must contact their insurance company directly.