Member Rights and Responsibilities

Member Rights & Responsibilities

You are the person responsible for your health! Mercy Health Plans works in partnership with you by making care available to you. There are certain rights and responsibilities that are a vital part of this partnership. How you exercise those rights and responsibilities affects Mercy Health Plans’ ability to help you and your covered dependents remain healthy and to make appropriate medical care available to all its Members. If you have any questions about this information, please Contact Us.

You are entitled...

To be treated with respect and dignity.

To receive advice or assistance in a prompt, courteous and responsible manner.

To choose your Primary Care Physician. You are asked to establish an ongoing relationship with your physician. Maintaining this relationship is an important part of your health care. You also have the right to change physicians if you so desire.

To confidentiality. All information concerning your enrollment and medical history is privileged and confidential except when disclosure is required by law or permitted in writing by you. You are entitled to access your medical records according to state and federal law; and with adequate notice, you have the right to review your medical records with your physician.

To information about your diagnosis, treatments and expected outcomes in terms that you understand. If the provider determines that the information could be detrimental to you, information is given to a person you designate or someone with legal authority.

To information about your health care plan, the network physicians and other health care providers providing your care.

To discuss health care concerns or complaints about Mercy Health Plans with those responsible for your care or with Mercy Health Plans, and to receive a response within a reasonable time period.

To participate in decisions about the kind of care you want or do not want. You should receive enough information to enable you to make an informed decision before you receive any recommended treatment. The information should include the specific procedure or treatment, medical alternatives and associated risks.

To have your guardian, next of kin or legally authorized person exercise your rights on your behalf if your medical condition makes you incapable of understanding or exercising your rights.

To receive information about the managed care organization, its services, its practitioners and providers, and Members’ rights and responsibilities.

To participate with practitioners in decision making regarding your health care.

To a candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.

To voice complaints or appeals about the managed care organization or the care provided.

Likewise, you are responsible for learning how your Mercy Health Plans coverage works. Becoming familiar with the information in this handbook and in your EOC Agreement is one way of meeting that responsibility.

The following is a list of other general responsibilities you have as a Mercy Health Plans Member.

You have the responsibility...

To treat all Mercy Health Plans and provider network personnel and other Members with respect and courtesy.

To provide, to the best of your knowledge, honest and complete information about matters relating to your health. If you do not understand, have questions or disagree with the treatment plan, you have the responsibility to discuss your concerns with the treatment staff and make certain you understand the explanations and instructions.

To carry your I.D. card at all times and never permit anyone else to use it.

To provide, to the extent possible, information that the managed care organization and its practitioners and providers need in order to care for you.

To follow the plans and instructions for care that you have agreed upon with your practitioners.

To be on time for appointments and notify the physician’s office promptly if you cannot keep an appointment.

To pay applicable copayments and to notify Mercy Health Plans of any additional sources of insurance coverage or reimbursement (e.g., Worker’s Compensation, etc.).

To notify your employer and Mercy Health Plans of address changes or changes in family status affecting eligibility or enrollment (e.g., marriage, birth, adoption, divorce, death or guardianship).

To express your opinions, concerns, or complaints in a constructive manner as outlined in this handbook to the appropriate people within Mercy Health Plans or the Mercy Health Plans network. Our Member Services Representatives are available Monday through Friday.

It is the shared responsibility of the Member and their Primary Care Physician and specialist to assure that referrals are obtained, and are accurate and current. Additionally, Members are responsible for verifying the approved date range of the referral, and the number of visits and types of services that have been authorized. Please verify this with your Primary Care Physician and/or Member Services. All referrals must be obtained prior to receiving services.