Common use of SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES Clause in Contracts

SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES. If a Member has questions, suggestions, problems, or concerns regarding benefits or services rendered, the HMO is ready to assist. Members should call Keystone’s Customer Service Department at the telephone number shown on their ID Card. A Keystone Representative will respond to any inquiry promptly. MEMBER RIGHTS Members have a right:  To be treated with respect and recognition of their dignity and right to privacy at all times, to receive considerate and respectful care regardless of religion, race, color, national origin, age, sex, gender identity or sexual orientation, health status, or financial status.  To receive information about Keystone, its services, its contracted practitioners and providers (including information regarding a provider’s qualifications, such as medical school attended, residency completed, or board certification status), and Member rights and responsibilities. Members can call Customer Service to obtain this information.  To make recommendations to the list of Member rights and responsibilities.  To have Keystone Member literature and material for the Member’s use, written in a manner which truthfully and accurately provides relevant information that is easily understood.  To know the name, professional status, and function of those involved in their care.  To obtain from their physician complete current information concerning their diagnosis, treatment, and prognosis in terms they can reasonably understand, unless it is not medically advisable to provide such information.  To candid discussion of appropriate or Medically Necessary treatment options for their condition, regardless of cost or benefit coverage.  To participate with practitioners in decision making regarding their health care.  To know what procedure and treatment will be used so that when they give consent to treatment, it is truly informed consent. Members should be informed of any side effects or complications that may arise from proposed procedures and treatment in addition to possible alternative procedures. Their physician is responsible for providing them with information they can understand.  To be advised if any experimentation or research program is proposed in their case and of their right to refuse participation.  To refuse any drugs, treatment, or other procedure offered to them to the extent permitted by law and to be informed by their physician of the medical consequences of such refusal.  To all information contained in their medical record unless access is specifically restricted by the attending physician for medical reasons.  To expect that all records pertaining to their medical care are treated as confidential unless disclosure is necessary for treatment, payment and operations.  To be afforded the opportunity to approve or refuse release of identifiable personal information except when such release is allowed or required by law.  To file Complaints or Grievances about Keystone, services requested, or the care rendered by their provider. MEMBER RESPONSIBILITY Members have a responsibility:  To follow the rules of Membership and to read all materials carefully.  To carry their Keystone ID card with them and present it when seeking health care services.  To provide Keystone with relevant information concerning any additional health insurance coverage which they or any of their dependents may have.  To timely notify Keystone and their employer of any changes in their Membership, such as change of address, marital status, etc.  To seek and obtain services from the PCP they have chosen as well as direct access to obstetrical/gynecological care and in emergencies or when their chosen physician has referred them to other Participating Providers and/or Keystone has preauthorized them to do so.  To communicate openly with the physician they choose by developing a physician-patient relationship based on trust and cooperation.  To follow the plans and instructions for care that they have agreed upon with their practitioner.  To ask questions to make certain they understand the explanations and instructions they are given.  To understand their health problems and participate, to the degree possible, in developing mutually agreed upon treatment goals.  To understand the potential consequences if they refuse to comply with treatment plans or recommendations.  To keep scheduled appointments or give adequate notice of delay or cancellation.  To pay appropriate Copayments and Coinsurance to Providers when services are received.  To keep Keystone informed of any concerns regarding the medical care they receive.  To provide information, to the extent possible, that Keystone needs to administer coverage and that practitioners need to provide care.  To treat others with respect and recognition of dignity, and to provide considerate and respectful interaction with others regardless of their religion, race, color, national origin, age, or sex, gender identity or sexual orientation, health status or financial status.

SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES. If a Member has questions, suggestions, problems, or concerns regarding benefits or services rendered, the HMO is ready to assist. Members should call Keystone’s Customer Service Department at the telephone number shown on their ID Card. A Keystone Representative will respond to any inquiry promptly. MEMBER RIGHTS Members have a right:  To be treated with respect and recognition of their dignity and right to privacy at all times, to receive considerate and respectful care regardless of religion, race, color, national origin, age, sex, gender identity or sexual orientation, health status, or financial status.  To receive information about Keystone, its services, its contracted practitioners and providers (including information regarding a provider’s qualifications, such as medical school attended, residency completed, or board certification status), and Member rights and responsibilities. Members can call Customer Service to obtain this information.  To make recommendations to the list of Member rights and responsibilities.  To have Keystone Member literature and material for the Member’s use, written in a manner which truthfully and accurately provides relevant information that is easily understood.  To know the name, professional status, and function of those involved in their care.  To obtain from their physician complete current information concerning their diagnosis, treatment, and prognosis in terms they can reasonably understand, unless it is not medically advisable to provide such information.  To candid discussion of appropriate or Medically Necessary treatment options for their condition, regardless of cost or benefit coverage.  To participate with practitioners in decision making regarding their health care.  To know what procedure and treatment will be used so that when they give consent to treatment, it is truly informed consent. Members should be informed of any side effects or complications that may arise from proposed procedures and treatment in addition to possible alternative procedures. Their physician is responsible for providing them with information they can understand.  To be advised if any experimentation or research program is proposed in their case and of their right to refuse participation.  To refuse any drugs, treatment, or other procedure offered to them to the extent permitted by law and to be informed by their physician of the medical consequences of such refusal.  To all information contained in their medical record unless access is specifically restricted by the attending physician for medical reasons.  To expect that all records pertaining to their medical care are treated as confidential unless disclosure is necessary for treatment, payment and operations.  To be afforded the opportunity to approve or refuse release of identifiable personal information except when such release is allowed or required by law.  To file Complaints or Grievances about Keystone, services requested, or the care rendered by their provider. MEMBER RESPONSIBILITY Members have a responsibility:  To follow the rules of Membership and to read all materials carefully.  To carry their Keystone ID card with them and present it when seeking health care services.  To provide Keystone with relevant information concerning any additional health insurance coverage which they or any of their dependents may have.  To timely notify Keystone and their employer of any changes in their Membership, such as change of address, marital status, etc.  To seek and obtain services from the PCP they have chosen as well as direct access to obstetrical/gynecological care and in emergencies or when their chosen physician has referred them to other Participating Providers and/or Keystone has preauthorized them to do so.  To communicate openly with the physician they choose by developing a physician-patient relationship based on trust and cooperation.  To follow the plans and instructions for care that they have agreed upon with their practitioner.  To ask questions to make certain they understand the explanations and instructions they are given.  To understand their health problems and participate, to the degree possible, in developing mutually agreed upon treatment goals.  To understand the potential consequences if they refuse to comply with treatment plans or recommendations.  To keep scheduled appointments or give adequate notice of delay or cancellation.  To pay appropriate Copayments and Coinsurance to Providers when services are received.  To keep Keystone informed of any concerns regarding the medical care they receive.  To provide information, to the extent possible, that Keystone needs to administer coverage and that practitioners need to provide care.  To treat others with respect and recognition of dignity, and to provide considerate and respectful interaction with others regardless of their religion, race, color, national origin, age, or sex, gender identity or sexual orientation, health status or financial status. SECTION APP - MEMBER APPEAL PROCEDURES (Multi-State Plan) GENERAL INFORMATION FOR APPEAL OF AN ADVERSE BENEFIT DETERMINATION Members who are dissatisfied with an Adverse Benefit Determination of the HMO may appeal. An Adverse Benefit Determination is a denial (or partial denial), reduction or termination of or a failure to provide or make payment (in whole or in part) for a benefit. Examples of an Adverse Benefit Determination include both coverage issues as well as issues concerning Medical Necessity and appropriateness of a health care service including denials of coverage for services that are: for out of network care if available in-network; considered experimental/investigational or cosmetic; at an inappropriate level of care or setting or are ineffective or unjustified. A Member may also appeal a decision to rescind the Member’s coverage. Appeals of an Adverse Benefit Determination are classified as pre or post-service. This classification will affect the time available to HMO to conduct the appeal review. A pre-service appeal of an Adverse Benefit Determination is where the Member received a denial, reduction or termination of or a failure to provide or make payment for a benefit before services are received. One example of a pre-service Adverse Benefit Determination is where a Preauthorization has been requested and the HMO’s decision is not to authorize the services. A maximum of thirty (30) days is available to the HMO to issue a decision in a standard pre-service appeal. A post-service appeal of an Adverse Benefit Determination is an appeal of a denial, reduction or termination of or a failure to provide or make payment for a benefit for medical care or services that a Member has already received. A maximum of sixty (60) days is available to the HMO to issue a decision in a standard post-service appeal.