Member Rights. The Subscriber Agreement (SA) shall include a complete statement that a Member shall have the right to: Available and accessible services when medically necessary, 24 hours per day, 7 days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; Be treated with courtesy and consideration, and with respect for the Covered Person's dignity and need for privacy; Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; Receive from the Covered Person's Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if the Covered Person 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 Covered Person's medical record; All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; To the extent available and applicable to us, to affordable health care, with limits on Out-of-pocket expenses, including the right to seek care from a non-participating (Out-of-network) Provider, and an explanation of a Covered Person's financial responsibility when services are provided by a non- participating (Out-of-network) Provider, or provided without required Prior Authorization; An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 4 contracts
Samples: Subscriber Agreement, Subscriber Agreement, Subscriber Agreement
Member Rights. The Subscriber Agreement (SA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 3 contracts
Samples: Subscriber Agreement, Subscriber Agreement, Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner Provider (PCP) within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; and • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 2 contracts
Samples: Group Subscriber Agreement, Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours per day, 7 seven days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the AgreementGSA; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health PlanInsurance Company, Inc., and the benefits provided; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan Insurance Company, Inc. and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) Provider, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 2 contracts
Samples: Group Subscriber Agreement, Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 seven (7) days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health care, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 2 contracts
Samples: Group Subscriber Agreement, Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: Available and accessible services when medically necessary, 24 hours hour per day, 7 days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating or (Out-ofof- network (outside of the 5-networkcounty area) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-of-networknetwork (outside of the 5-county area) Provider, or provided without required Prior Authorization; An approved example of the financial responsibility incurred by a Covered Person when going Out-of-networknetwork (outside of the 5-county area); inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network (outside of the 5-county area) Coverage; Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 2 contracts
Samples: Group Subscriber Agreement, Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner PCP within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; and • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 2 contracts
Samples: Group Subscriber Agreement, Group Subscriber Agreement
Member Rights. The Subscriber Agreement (SA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 seven days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner PCP within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health care, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-ofof- network (outside of the 5-networkcounty area)) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-of-networknetwork (outside of the 5-county area)) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-networknetwork (outside of the 5-county area); inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network (outside of the 5-county area) Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 2 contracts
Samples: Subscriber Agreement, Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 seven (7) days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health care, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating or (Out-ofof- network (outside of the 5-networkcounty area) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-of-networknetwork (outside of the 5-county area) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-networknetwork (outside of the 5-county area); inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network (outside of the 5-county area) Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: Available and accessible services when medically necessary, 24 hours per day, 7 days per week for Urgent urgent or Emergency Health Care Services, and for other Health Care Services health care services as defined by the AgreementGSA; Be treated with courtesy and consideration, and with respect for the Covered Person's dignity and need for privacy; Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; To choose a Primary Care Practitioner within the limits of the Covered BenefitsInsurance Company, plan networkInc., and as provided by this rule, including the right to refuse care of specific Health Care Professionalsbenefits provided; Receive from the Covered Person's Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if the Covered Person 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 Covered Person's medical record; All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; Know upon request of any financial arrangements or provisions between Presbyterian Health Plan Insurance Company, Inc., and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; To the extent available and applicable to us, to affordable health careHealth Care, with limits on Out-of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) Provider, and an explanation of a Covered Person's financial responsibility when services are provided by a non- non-participating (Out-of-network) Provider, or provided without required Prior Authorization; An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: Available and accessible services when medically necessary, 24 hours per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; To choose a Primary Care Practitioner Provider (PCP) within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; File a Complaint Grievance or Appeal with us or the Superintendent and to receive an answer to those Complaints Grievances in accordance with existing law; Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner PCP within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: Available and accessible services when medically necessary, 24 hours per day, 7 days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; Be treated with courtesy and consideration, and with respect for the Covered Person's dignity and need for privacy; Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; Receive from the Covered Person's Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if the Covered Person 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 Covered Person's medical record; All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; To the extent available and applicable to us, to affordable health care, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: Available and accessible services when medically necessary, 24 hours per day, 7 days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; Be treated with courtesy and consideration, and with respect for the Covered Person's dignity and need for privacy; Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; Receive from the Covered Person's Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if the Covered Person 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 Covered Person's medical record; All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; To the extent available and applicable to us, to affordable health care, with limits on Out-of-of- pocket expenses, including the right to seek care from a non-participating (Out-of-network) Provider, in urgent or emergent situations only, and an explanation of a Covered Person's financial responsibility when services are provided by a non- non-participating (Out-of-network) Provider, or provided without required Prior Authorization; An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Subscriber Agreement (SA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: · Available and accessible services when medically necessary, 24 hours per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be · A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; · Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; · To choose a Primary Care Practitioner Provider (PCP) within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; · Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; · All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; · Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; · File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; · Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; · Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; · Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; · To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; · An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; · Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; and · A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: · Available and accessible services when medically necessary, 24 hours hour per day, 7 days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be · A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; · Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; · To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; · Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; · All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; · Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; · File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; · Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; · Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; · Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; · To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating or (Out-ofof- network (outside of the 5-networkcounty area) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-of-networknetwork (outside of the 5-county area) Provider, or provided without required Prior Authorization; · An approved example of the financial responsibility incurred by a Covered Person when going Out-of-networknetwork (outside of the 5-county area); inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network (outside of the 5-county area) Coverage; · Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; · A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: · Available and accessible services when medically necessary, 24 hours per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be · A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; · Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; · To choose a Primary Care Practitioner Provider (PCP) within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; · Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; · All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; · Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; · File a Complaint Grievance or Appeal with us or the Superintendent and to receive an answer to those Complaints Grievances in accordance with existing law; · Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; · Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; · Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; · To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; · An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; · Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; · A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Subscriber Agreement (SA) shall include a complete statement that a Member shall have the right to: ⮚ Available and accessible services when medically necessary, 24 hours per day, 7 days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; ⮚ Be treated with courtesy and consideration, and with respect for the Covered Person's dignity and need for privacy; ⮚ Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; ⮚ To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; ⮚ Receive from the Covered Person's Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if the Covered Person 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 Covered Person's medical record; ⮚ All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; ⮚ Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; ⮚ File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; ⮚ Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; ⮚ Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; ⮚ Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; ⮚ To the extent available and applicable to us, to affordable health care, with limits on Out-of-pocket expenses, including the right to seek care from a non-participating (Out-of-network) Provider, and an explanation of a Covered Person's financial responsibility when services are provided by a non- participating (Out-of-network) Provider, or provided without required Prior Authorization; ⮚ An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; ⮚ Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; ⮚ A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the AgreementGSA; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health PlanInsurance Company, Inc., and the benefits provided; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan Insurance Company, Inc. and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health care, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) Provider, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Subscriber Agreement (SA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; To • The insured has the freedom to choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Full freedom to choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Healthcare Professionals; Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if the Covered Person 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 Covered Person's ’s medical record; • Receive from the Covered Person’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; of the Covered Person 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 Covered Person’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner Provider (PCP) within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint Grievance or Appeal with us or the Superintendent and to receive an answer to those Complaints Grievances in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: Available and accessible services when medically necessary, 24 hours hour per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; To choose a Primary Care Practitioner PCP within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; and A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours per day, 7 seven (7) days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health care, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Subscriber Agreement (SA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 seven days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner PCP within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health care, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-ofof- network (outside of the 5-networkcounty area)) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-of-networknetwork (outside of the 5-county area)) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-networknetwork (outside of the 5-county area); inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network (outside of the 5-county area) Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating or (Out-ofof- network (outside of the 5-networkcounty area) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-of-networknetwork (outside of the 5-county area) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-networknetwork (outside of the 5-county area); inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network (outside of the 5-county area) Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health care, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: ➢ Available and accessible services when medically necessary, 24 hours per day, 7 days per week for Urgent or Emergency Health Care Services, and for other Health Care Services as defined by the Agreement; ➢ Be treated with courtesy and consideration, and with respect for the Covered Person's dignity and need for privacy; ➢ Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; ➢ To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Professionals; ➢ Receive from the Covered Person's Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if the Covered Person 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 Covered Person's medical record; ➢ All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; ➢ Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; ➢ File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; ➢ Privacy of medical and financial records maintained by us and our Health Care Providers, in accordance with existing law; ➢ Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; ➢ Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; ➢ To the extent available and applicable to us, to affordable health care, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; ➢ An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's “billing examples” requires written approval by the Superintendent, in our Health Care Benefit Plan that provides benefits for Out-of-network Coverage; ➢ Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; ➢ A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours hour per day, 7 seven (7) days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating or (Out-ofof- network (outside of the 5-networkcounty area) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-of-networknetwork (outside of the 5-county area) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-networknetwork (outside of the 5-county area); inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network (outside of the 5-county area) Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
Member Rights. The Group Subscriber Agreement (SAGSA) shall include a complete statement that a Member shall have the right to: • Available and accessible services when medically necessary, 24 hours per day, 7 seven days per week for Urgent or Emergency Health Care Healthcare Services, and for other Health Care Healthcare Services as defined by the Agreement; Be • A right to be treated with courtesy respect and consideration, and with respect for the Covered Person's recognition of their dignity and need for their right to privacy; • Be provided with information concerning our policies and procedures regarding products, services, Providers, Appeals procedures and other information about Presbyterian Health Plan; • To choose a Primary Care Practitioner Provider (PCP) within the limits of the Covered Benefits, plan network, and as provided by this rule, including the right to refuse care of specific Health Care Healthcare Professionals; • Receive from the Covered Person's ’s Physician(s) or Provider, in terms that the Covered Person understands, an explanation of his or her complete medical condition, recommended treatment, risk(s) of the treatment, expected results and reasonable medical alternatives, irrespective of our position on treatment options; if of the Covered Person 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 Covered Person's ’s medical record; • All the rights afforded by law, rule, or regulation as a patient in a licensed Health Care Healthcare Facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the Covered Person understands; • Prompt notification, as required in this rule, of termination or changes in benefits, services or Practitioner/Provider network; • File a Complaint or Appeal with us or the Superintendent and to receive an answer to those Complaints in accordance with existing law; • Privacy of medical and financial records maintained by us and our Health Care Healthcare Providers, in accordance with existing law; • Know upon request of any financial arrangements or provisions between Presbyterian Health Plan and our Practitioners/Providers which may restrict referral or treatment options or limit the services offered to Covered Persons; • Adequate access to qualified Health Professionals for the treatment of Covered Benefits near where the Covered Person lives or works within our Service Area; • To the extent available and applicable to us, to affordable health carehealthcare, with limits on Out-Out- of-pocket expenses, including the right to seek care from a non-participating (Out-of-of- network) ProviderProvider in urgent or emergent situations only, and an explanation of a Covered Person's ’s financial responsibility when services are provided by a non- non-participating (Out-Out- of-network) Provider, or provided without required Prior Authorization; • An approved example of the financial responsibility incurred by a Covered Person when going Out-of-network; inclusion of the entire “billing examples” provided by the Superintendent available on the Division's ’s website at the time of the filing of the plan will be deemed satisfaction of this requirement; any substitution for, or changes to, the Division's ’s “billing examples” requires written approval by the Superintendent, in our Health Care Healthcare Benefit Plan that provides benefits for Out-of-network Coverage; • Detailed information about Coverage, Maximum Benefits, and Exclusions of specific conditions, ailments or disorders, including restricted Prescription benefits, and all requirements that a Covered Person must follow for Prior Authorization and Utilization Review; and • A complete explanation of why care is denied, an opportunity to Appeal the decision to our internal review, the right to a secondary Appeal, and the right to request the Superintendent’s assistance.
Appears in 1 contract
Samples: Group Subscriber Agreement
