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MEMBER'S RIGHTS AND RESPONSIBILITIES YOUR RIGHTS - Members have the right to receive high quality health care in a manner that shows respect for their privacy and dignity.
- Members have the right to participate with practitioners in any diagnosis, prognosis, and continued course of treatment, in a manner that can be understood.
- Members have the right to be asked to give their informed consent prior to medical treatment, except in the case of a life-threatening emergency.
- Members have the right to know the name, professional status, and function of all health care professionals who provide health care services to them.
- Members have the right to have all medical records and other information pertaining to their medical care treated confidentially, unless release of such information is required by law.
- Members have the right to be informed of the policies and procedures that apply to their conduct as a member of Arnett Health Plans.
- Members have the right to access literature and materials that provide accurate information about Arnett HealthPlans and are written in a manner that can be understood.
- Members have the right to report a concern or complaint about the staff or operations of Arnett HealthPlans, or the care provided, and to receive timely responses to those concerns or complaints.
- The right to make recommendations regarding the organizations members' rights and responsibilities.
YOUR RESPONSIBILITIES - Members are responsible for understanding the benefits and exclusions that are described in their Member Certificate and Agreement.
- Members are responsible for paying any co-payments or deductibles required by this plan at the time service is rendered or goods are received.
- Members are responsible for establishing a relationship with an Arnett HealthPlans primary care physician and for seeking care only from him or her, except in a life-threatening emergency or upon approved referral to a specialist.
- Members are responsible for seeking information from your primary care physician concerning any diagnosis, prognosis, and continued course of treatment.
- Members are responsible for to follow the plans and instructions for care that has been agreed upon by you and your practitioners.
- Members are responsible for assisting their primary care physician in assembling your medical records by authorizing him or her to obtain medical information from other physicians.
- Members are responsible for keeping their practitioners informed concerning the status of their health and any changes that could influence the course of their treatment.
- Members are responsible for considering all potential consequences of refusing to comply with their practitioners' recommendations.
- Members are responsible to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
- Members are responsible for constructively expressing any concern, complaint, or suggestion they may have concerning the staff or operations of Arnett HealthPlans.
- Members are responsible for treating Arnett HealthPlans staff members and providers considerately and for respecting the rights of other members.
Utilizaton Service Guidelines
When you need to see a specialist, your Primary Care Physician will refer you to a participating specialist within the Arnett HealthPlans Provider Network. To help your doctor provide you with the best care and service, it may be necessary to coordinate authorization of some procedures with Arnett Health Plans. This team effort helps to ensure that your care is directed to a Network Provider and the service is a benefit of your health plan. Your referral and medical history is evaluated for appropriateness of care and service, utilizing nationally recognized guidelines.
Arnett HealthPlan's Utilization Management Committee, comprised of Plan Primary Care Physician and Specialists, annually review the guidelines to ensure quality and safety. Only those guidelines, which meet the committee's strict criteria, are used to evaluate your requests.
Referral requests are approved or denied based upon your eligibility, benefit and medical history. Arnett HealthPlans does not reward doctors or other individuals conducting referral review for denying coverage or service. All Arnett HealthPlans Utilization Management staff are salaried employees and do not receive any incentives based upon the number of patient referrals approved or denied. Your doctor is available to provide or coordinate all of your care. He or she is not given an incentive to keep from referring you to a specialist for medically necessary care.
Remember, your PCP wants to help you live a healthy, active life. If you think you need to see a specialist, talk with your PCP. He or she will make sure you get the care that is right for you. |
