Our members have certain rights and responsibilities to help uphold the quality of care and services they receive from you. We list the rights and responsibilities in the member materials for commercial and MA benefit plans.
Members have the right to appeal the determination of any denied services or claims by filing an appeal. Time frames for filing an appeal vary depending on applicable state or federal requirements.
We maintain a system of logging, tracking and analyzing issues received from members and care providers. We use the information to measure and improve member and care provider satisfaction. This system helps us fulfill the requirements and expectations of our members and our network care providers. In addition, it supports compliance with the Centers for
Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), The Joint Commission, and other accrediting and/or regulatory requirements.
We acknowledge and enter all written complaints into the complaint database. If we identify a potential quality of care issue within the complaint (using pre-established triggers), we forward the case to the Quality of Care Department to investigate. If the complaint involves an imminent and serious threat to the member’s health, the case is referred to Quality Intervention Services for immediate action.
We identify and request relevant medical records and information needed to resolve quality of care investigations. We use the results to assign severity levels and data collection codes. This helps us objectively and systemically monitor, evaluate and improve the quality and safety of clinical care and quality of service provided to our members.
We track and trend care provider complaints and use the information during their recredentialing. We conduct an annual analysis of the complaint data to look for opportunities for improvement. Care provider and member complaints are important to the recredentialing process because they help us attract and retain care providers, employer groups and members.
The state and federal government allows an individual, other than the subscriber, to request confidential treatment as it relates to:
We require our members to submit written requests for confidential status to you. The request must include their current address, private phone number, and date and time you received it. Having a written request prevents disagreements regarding the accuracy of their personal contact information. Members are responsible for resubmitting new confidentiality forms if their information changes.
HIPAA Privacy Regulations provide federal protection for the privacy of health care information. These regulations control the internal and external uses of health information. They also create certain individual patient rights. Information related to our privacy practices can be found on uhc.com > Privacy.
The federal Patient Self-Determination Act (PSDA) gives patients the legal right to make choices about their medical care prior to a severe illness or injury through an advance directive. Under the federal act, care providers and facilities must:
We also inform members about state laws on advance directives through our member’s benefit material. We encourage these discussions with our members.
Information is also available from the Robert Wood Foundation, Five Wishes. The information there meets the legal requirements for an advance directive in certain states and may be helpful to members. Five Wishes is available on AgingWithDignity.org.