Members have the right to:

• Receive information about the organization, its services, its practitioners and providers and member rights and responsibilities
• To be treated with respect and recognition of their dignity and right to privacy
• To participate with practitioners in making decisions about their health care
• To a candid discussion of appropriate or medically necessary treatment options of their conditions, regardless of cost or benefit coverage
• To voice complaints or appeals about the organization or the care it provides
• To make recommendations regarding the organization’s member rights and responsibilities policies

Members have the responsibility to:

• Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care
• To follow plans and instructions for care that they have agreed on with their practitioners
• To understand their health problems and participate in developing mutually agreed-upon treatment goals to the degree possible

• Utilization Management decision making is based solely on appropriateness of care and service and existence of coverage. Your group does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization.
• If you want to obtain a copy of the decision making criteria utilized by your group for service decisions, this information is made available to the public upon request by contacting our Member Services Department at (800) 611-0111. The group is only required to disclose the criteria or guidelines for specific procedures or conditions requested.

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