Member Resources

Your Questions Answered.

Thanks for choosing a pediatrician with CPMG, where our only focus is health care for kids. Below you’ll find answers to some of the most commonly asked questions we get from our members.

Do you provide case management services?

Yes, we do. Please call our Customer Service Department at 1-877-276-4543 to receive case management services from one of our nurses.

What is an authorization and how does the authorization process work?

CPMG believes your child should get high-quality care as quickly as possible. Therefore, we only require authorizations for services when absolutely necessary. If your child is referred for a medical service that requires authorization, the referring doctor will send a request to Children’s Physicians Medical Group (CPMG). The request is reviewed by CPMG clinical staff.

You and your doctor will be notified by mail of any decision, whether authorized or denied. Authorization letters will include information on types of services approved, the number of services approved and the name of the provider who will care for your child. If a denial of coverage is issued, you have the right to appeal that decision with your health plan. You will receive a letter with information on how to appeal the denial.

Any policies or clinical criteria used to make an authorization decision are available upon request from CPMG. If you have any questions about this process or your authorization request, please contact us.

What services require prior authorization?
  • Acupuncture
  • Chiropractic
  • Cochlear Implants and supplies
  • CT Scans (only when diagnosis is headache)
  • Dental Anesthesia
  • Durable Medical Equipment (DME)
  • Genetic Testing
  • Hearing Aids and supplies
  • Home Health Services
  • Infusion
  • Injectable Medications
  • Inpatient Admissions
  • MRI (only when diagnosis is headache)
  • Nutrition/Weight Management
  • Occupational Therapy
  • Orthotics / Prosthetics
  • Out of Network Services
  • PET Scans
  • Physical Therapy
  • Speech Therapy
  • Transplants
How is an authorization decision made?
  • Authorization decisions are based on several things:
    • Clinical information provided
    • Benefits and coverage of your health insurance plan
    • Your health plan’s medical policies
    • Use of the CPMG network of providers

    Because it might be a concern, please know that CPMG utilization-management decision making is based only on appropriateness of care, services and existence of coverage. The providers or other individuals conducting utilization review for coverage or services are not compensated for denials and/or encouraged for barriers to care or services. Incentives are not used to reward inappropriate restriction of care.

    Should you wish to see our policy statement, a copy of the Affirmative Statement can be found by clicking here.

How do I contact my doctor after hours or on weekends?

Call your doctor’s office first, anytime, day or night. Your doctor or nurse will give you medical advice and, if needed, send you to the right place to receive the care your child needs.

Which Urgent Care should I go to?

If advised to take your child to Urgent Care, you have many choices covered by your insurance. You can easily look up a conveniently located Urgent Care site here.

How do I know if a doctor is in network?

Ask your pediatrician first. You can also search by doctor name or specialty on our “Find a Doctor” page.

How do I find a speech, occupational or physical therapy provider?

FREE services are available through your school district. Click here for contact information. Rady Children’s Hospital-San Diego offers pediatric therapy services in several locations. For occupational or physical therapy, call (858) 966-5829. For speech therapy, call (858) 966-5838. Additional contracted providers can be found here.

What if I want a second opinion?

Member-requested second opinions are authorized by your health plan. You may contact them through the member services phone number on your insurance card for assistance.

How do I file a complaint?

Complaints and grievances are handled by your health plan. Contact the member services phone number on your insurance card for assistance.

Member Bill of Rights

“Dr. Barbadillo was my doctor when I was a baby and now that I have a baby she is her doctor. I love her clinic, it’s always neat and clean. Just wanted to say thank you!”

– Anonymous

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