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Members Rights and Responsibilities
Each Presbyterian member (or their legal guardian) shall have the right:
1. To receive information about Presbyterian, its healthcare services and benefits, how to access those services, its practitioners and providers, its appeals process, its policies and procedures, and members' rights and responsibilities.
2. To be treated equitably with courtesy and consideration, with respect and recognition of the member's dignity and right to privacy.
3. To participate with practitioners in making decisions about all aspects of their health care.
4. To a candid discussion and explanation of appropriate or medically necessary treatment options or healthcare decisions for their conditions, regardless of cost or benefit coverage.
5. To voice complaints, grievances or appeals with Presbyterian or its regulatory bodies about Presbyterian or the care it provides. The member also has the right to receive an answer to such within a reasonable time and without fear of retaliation.
6. To make recommendations regarding the Presbyterian's members' rights and responsibilities policy.
7. To receive healthcare services in a non-discriminatory fashion. No member may be denied the benefits of, or participation in, covered services on the basis of race, color, sex, sexual preference, age, handicap, cultural or educational background, religion or national origin, economic or health status, or source of payment for care. Presbyterian is in conformance with the Americans with Disabilities Act of 1990 and other federal and state laws and regulations.
8. To detailed information about coverage, maximum benefits, and exclusions of specific conditions, ailments or disorders, including restricted prescription benefits, and all requirements that an enrollee must follow for prior authorization and utilization review.
9. Members who have a disability shall have the right to receive any information in an alternative format in compliance with the Americans with Disabilities Act.
10. To choose a primary care physician near where the member lives or works, within the service area, and within the limits of the covered benefits, plan network, and its referral and prior authorization requirements.
11. To know the names and professional status of individuals participating in the member's treatment, having timely access to the provider/practitioner primarily responsible for care, and referrals to specialist when medically necessary.
12. To change primary care practitioners by following the rules described in their agreement handbook, group subscriber agreement, or evidence of coverage.
13. To prompt notification of termination or changes in benefits, services or provider network.
14. To reasonable continuity of care sufficient to permit coordinated transition planning consistent with the members condition and needs when a provider/practitioner leaves the Presbyterian network or if a member's provider/practitioner is not in the Presbyterian network.
15. To available and accessible services when medically necessary as determined by the primary care or treating physician in consultation with Presbyterian, 24 hours per day, 7 days per week for urgent or emergency care services, and for other healthcare services as defined by the contract or the evidence of coverage.
Members may self-refer to emergency when the member believes they have a medical condition that could seriously jeopardize health, cause serious impairment to bodily functions, or create a serious dysfunction of any bodily organ or part. Referral or prior approval is not required.
16. To seek a second opinion for surgery by another provider in the Presbyterian network when members need additional information or clarification regarding recommended treatment or believe the provider is not authorizing requested care.
17. To affordable health care, with limits on out-of-pocket expenses, including the right to seek care from a non-participating provider, and an explanation of an enrollee's financial responsibility when services are provided by a non-participating provider, or provided without required prior authorization; (not applicable to Salud).
18. To choose a surrogate decision-maker to be involved as appropriate, to assist with care decisions.
19. To receive from the physician(s) or provider, in terms that the member understands, an explanation of their complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of Presbyterian's position on treatment options.
If the member is not capable of understanding the information, the explanation shall be provided to his or her next of kin, guardian, agent or surrogate, if available, and documented in the member's medical record.
20. To give informed consent based on information sufficient to permit a reasonably prudent person to make an informed decision about the proposed treatment, the inherent and potential hazards of the proposed treatment and hereby result if the condition remains untreated.
21. To all the rights afforded by law, rule, or regulation to refuse any of the following, accepting responsibility after possible consequences of this decision have been explained in language the member understands:
- Leaving a medical facility against the advice of the practitioners
- A specific provider/practitioner
- Participation in experimentation/research affecting care or treatment
22. To make their wishes known through advance directives regarding health care decisions (i.e. living wills, right to die directives, "do not resuscitate" orders, etc.) consistent with federal and state laws and regulations.
23. To be advised of continuing health care requirements following discharge from in-patient or out-patient facilities.
24. To know upon request of any financial arrangements or provisions between Presbyterian and its providers which may restrict referral or treatment options or limit the services offered to members.
25. To appeal decisions made by Presbyterian and the right to a complete explanation of why care is denied. Members have an opportunity to appeal the decision to the health care insurer's internal review process, and the right to request assistance from Presbyterian's regulatory bodies.
26. To privacy of medical and financial records maintained by Presbyterian and its health care providers. Such records shall be kept in accordance with all federal and state laws and regulations.
27. To access medical records in accordance with all applicable federal and state laws and regulations.
28. To be free from harassment Presbyterian or its network providers in regard to contractual disputes between Presbyterian and providers.
Members shall have the right to select an MCO and exercise switch enrollment rights without threats or harassment.
Members shall have the right to receive a Certificate of Creditable Coverage when a member's enrollment in Presbyterian terminates.
Presbyterian expects members to cooperate responsibly in matters regarding their health care, including the following:
1. Members shall have a responsibility to provide, whenever possible, information that Presbyterian and its providers need in order to care for them.
2. Members shall have a responsibility to follow the plans and instructions for care that they have agreed upon with their practitioners or providers. A member may, for personal reasons, refuse to accept treatment recommended by their practitioners or providers. Such refusal may be regarded as incompatible with the continuance of the practitioner-patient relationship and as obstructing the provision of proper medical care.
3. Member shall have a responsibility to understand the their health problems and to participate in developing mutually agreed upon treatment plans and goals.
4. Each member must ensure that information given in application for enrollment, questionnaires, forms or correspondence is true and complete. Members also have a responsibility to notify Presbyterian of any changes in names, address, phone number, marital status, or newborns that affect eligibility. Presbyterian Salud members must notify HSD and Commercial members must notify the health plan of changes within 31 days.
5. Each member is expected to advise a participating provider/practitioner of coverage with Presbyterian at the time of service. Members may be required to pay for services if they do not inform their participating provider/practitioner of their Presbyterian coverage.
6. Each member is required to pay all applicable co-payments at the time services are rendered, and show the ID card prior to receiving medical services or be billed for rendered services.
7. Members must not allow any other person to use his/her Presbyterian identification card and to notify Presbyterian immediately of any loss or theft of their Presbyterian identification card.
8. Members shall have a responsibility to keep appointments. If a member is unable to keep a scheduled appointment, they are expected to reschedule or cancel an appointment 24 hours in advance, if possible.
9. Each member is responsible for treating practitioners/ providers and other health care employees with respect and courtesy. Presbyterian provides guidelines for identifying and referring members who are disruptive, unruly, abusive or uncooperative to the point that his/her continuing membership seriously impairs the ability to furnish services to the member. Presbyterian works with practitioners to make recommendations and alternative approaches to care. Member Services will provide assistance in these situations.
Commercial Members must also:
1. Review their Group Subscriber Agreement (GSA) and if there are questions contact the Member Services Department at (505) 923-5678 or toll-free at 1-800-356-2219 for clarification of benefits, limitations, and exclusions outlined in the group subscriber agreement.
2. Be responsible for the payment of all services obtained prior to the effective date of their agreement with Presbyterian and subsequent to its termination or cancellation.
3. Be informed of the potential consequences of providing incorrect or incomplete information to Presbyterian, as described in this agreement.
Salud Members must also:
1. Present a current Medicaid card and evidence of any other health insurance to a medical provider each time service is requested.
2. Be responsible for any financial liability incurred if he/she fails to furnish current Medicaid eligibility identification before receipt of a service and as a result the provider fails to adhere to MAD policies, such as failure to request prior approval. If this omission occurs, the settlement of claims for services is between the member and the provider. A member is financially responsible for services received if he/she was not eligible for Medicaid on the date services were provided.
3. If a member fails to notify a provider that he/she has received services that are limited by time or amount, the member is responsible to pay for services if, before furnishing the services, the provider makes reasonable efforts to verify whether the recipient has already received services.