Patient Rights

The member has the right to:

1. Members are encouraged to seek emergency care at both in-network and out-of-network hospitals as needed. Our goal is to ensure that you receive timely and appropriate medical attention during emergencies, regardless of the hospital's network status. For all other care, including urgent and routine care, please visit your primary care physician, clinic, or available in-network urgent care facilities.
2. Exercise these rights without regard to gender, sexual orientation or cultural, economic, educational or religious background.
3. Be provided with comprehensible information about our medical group, services, providers and the healthcare service delivery process. This information includes instructions about how to obtain care with various providers and at varied facilities (e.g., primary care, specialty care, behavioral health services, and hospital services). Additionally, information will be included about how to obtain services outside the IPA system or service area.
4. Be informed of emergent and non-emergent benefit coverage and cost of care, and receive an explanation of the member’s financial obligations as appropriate, prior to incurring the expense (including co-payments, deductibles and co-insurance).
5. Be provided with instructions in accordance with prudent layperson standards and address the needs of non-English speaking members with information about how to obtain care after normal office hours and how to obtain emergency care including when to directly access emergency care or use 911 services.
6. Receive and examine an explanation of bills generated for services delivered to the member.
7. Be provided with information on how to submit a claim for covered services.
8. Be informed of the name and qualifications of the physician who has primary responsibility for coordinating the member’s care; and be informed of the names, qualifications and specialties of other physicians and non-physicians who are involved in the member’s care.
9. Have 24-hour, 7 days a week access to the member’s primary care physician (or covering physician).
10. Receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, and prospects for recovery in terms that are understandable to the member, to give informed consent or to refuse that course of treatment.
11. Candidly discuss appropriate or medically necessary treatment options for the member’s condition, regardless of cost or benefit coverage.
12. Actively participate in decisions regarding the member’s healthcare and treatment to the extent permitted by law. This includes the right to refuse any procedure or treatment. If the recommended procedure or treatment is refused, an explanation will be given addressing the effect that this will have on the member’s health.
13. Be treated with respect and dignity.
14. Receive considerate and respectful care with full consideration of the member’s privacy.
15. Receive confidential treatment of all member information and records used for any purpose.
16. Be informed of applicable rules in the various health care settings regarding member conduct.
17. Express opinions or concerns about our medical group or the care provided and offer recommendations for change in the healthcare service delivery process by contacting the Member Services Department.
18. Be informed of the member complaint/grievance and appeal process including how to express a complaint or appeal.
19. Be informed of the termination of a primary care provider or practice site and receive assistance in selecting a new primary care provider or site in this situation.
20. Change primary care physicians by contacting the Member Services Department at your health plan.
21. Be provided information on how we evaluate with health plans, new technology for inclusion as a covered benefit.
22. Receive reasonable continuity of care and be given timely and sensible responses to questions and requests made for service, care and payment (including complaints and appeals).
23. Be informed of continuing healthcare requirements following office visits, treatments, procedures and hospitalizations.
24. Have all member rights apply to the person who has the legal responsibility to make healthcare decisions for the member.
25. To make available and or assist Limited English Proficiency (LEP) members access to their contracted health plan interpreter services or when requested at any scheduled or unscheduled or unscheduled visits at provider offices, including ancillary providers, specialty service providers, diagnostic testing facilities, and urgent care at no cost to the member.
26. Right to make recommendations regarding  member rights and responsibilities policies.
27. Request enrollment in, or to decline or disenroll from, case management and/or disease management programs.
28. For any member denial the member will be able to contact the Medical Group and request a copy of the criteria used to make the decision on a denial that the group has made.

Member Responsibilities Policy

The member has the responsibility to:

1. Be familiar with the benefits and exclusions of the member’s health plan coverage.
2. Provide the member’s healthcare provider with complete and accurate information necessary for the care of the member (to the extent possible).
3. Be on time for all appointments and notify the provider’s office as far in advance as possible for appointment cancellation or rescheduling.
4. Report changes in the member’s condition according to provider instructions.
5. Inform providers of the member’s inability to understand the information given to him/her.
6. Carry out the treatment plan that has been developed and agreed upon by the healthcare provider and the member.
7. Contact the member’s primary care physician (or covering physician) for any care needed after that physician’s normal office hours.
8. Treat the healthcare provider and staff with respect.
9. Obtain an authorized referral from the member’s primary care physician for a visit to a specialist and/or to receive specialty care.
10. Be familiar and comply with our healthcare service delivery system regarding access to routine, urgent and emergent care.
11. Contact the Member Services Department or the member’s health plan Member Services Department regarding questions and assistance.
12. Respect the rights, property and environment of all physician and medical group providers, staff and other members.
13. Have all of these responsibilities apply to the person who has the legal responsibility to make healthcare decisions for the member.
14. Make recommendations regarding our member rights and responsibilities.

Some important notes for our members and providers:

We and our affiliates do not reward or offer incentives to employees or associates to encourage inappropriate under-utilization of services. We are committed to providing quality care to our members, and therefore:

1. Utilization Management decision-making is based only on appropriateness of care and service and existence of coverage.
2. We do not specifically reward practitioners or other individuals for issuing denials of coverage or service care.
3. Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization.

For any questions regarding the Utilization Management decision making or other issues related to the Utilization Management process, please call toll-free (866) 654-3471.

Language Assistance/Interpreter Services

In accordance with California Assembly Bill 853, all of our medical group providers will provide, at no cost to the member, Language Assistance/Interpreter Services for those who are limited in English proficiency. Ask your primary care physician for assistance if you need help with interpreter services.