Member & Practitioner Rights & Responsibilities
As partners in health care, each of us has rights and responsibilities that we must follow in order to make the most of our members’ health benefits. The following rights and responsibilities apply to our members:
Your Member Rights
You have the right to:
- Receive information about the health plan, its services, its practitioners and providers, and member's rights and responsibilities.
- Treatment with respect, consideration, dignity and right to privacy.
- Information about all services available through your health plan, including how to obtain emergency and after-hours care.
- Confidentiality of your medical records.
- Candid discussions concerning appropriate or medically necessary treatment options for your condition(s), regardless of cost or benefit coverage.
- Voice complaints or appeals about the health plan or the care provided.
- Request to see your primary doctor instead of another member of his/her office staff for an office visit, if you are willing to wait for an available appointment.
- Make recommendations regarding the health plan's member right and responsibilities policies.
Your Patient Rights
As a patient, you have a right to expect the following from your physician or other provider:
- To participate in decisions concerning your health care.
- To refuse treatment to the extent permitted by law, and to be informed of the medical consequences of that action.
- To obtain from your physician or other health care provider complete and current information concerning a diagnosis, treatment, or prognosis, in terms you can reasonably be expected to understand. When it is not advisable to give such information to you, the information shall be made available to an appropriate person on your behalf.
- To receive information from your physician or other provider necessary to give informed consent prior to the start of any procedure.
- To know the name and qualifications of all your caregivers. Information can be obtained from the provider or the administrator of any healthcare facility.
- If you feel that your physician has not given you the kind of service you have the right to expect, you have the right to follow the complaint procedure for Quality of Care Access Review. Please refer to your member handbook or contact: Customer Service.
Your Member Responsibilities
- Establish yourself as a patient of the primary doctor you have selected by making an appointment with the doctor as soon as possible.
- Follow the instructions and guidance of healthcare providers.
- Provide honest and accurate information concerning your health history and status.
- Participate in understanding your heath problems and developing mutually agreed upon treatment goals.
- Follow carefully your health plan's policies and procedures as described in your member handbook and your contract(s) and rider(s).
- Be sure your Primary Care Physician coordinates any health care you receive in order to receive the highest level of benefits, if applicable.
- Carry your member ID card with you and present it when seeking health services.
- Advise your health plan of any changes which affect you or your family such as birth, change of address, or marriage.
- Submit all bills you have received from a non-participating provider within one year from the date of service.
- Notify your health plan when anyone included in your coverage becomes eligible for Medicare or any other group health insurance.
- Keep your health plan informed of your concerns about the medical care you receive.
- Pay appropriate co-payments or coinsurance to providers when services or supplies are received.