Member rights and responsibilities

Our members have rights and responsibilities when participating in an MCO. Member Services representatives serve as advocates for Wellpoint members.

Members have the right to:

• Be treated respectfully and with due consideration for dignity and privacy
• Privacy during a visit with their doctor
• Talk about their medical record with their PCP, ask for a summary of that record and request to amend or correct the record as appropriate
• Be properly educated about and helped to understand their illness and available health care options, including a candid discussion of appropriate clinically or medically necessary treatment options, including medication treatment options regardless of the cost or benefit coverage
• Participate in decision‑making about the health care services they receive
• Refuse health care (to the extent of the law) and understand the consequences of their refusal
• Be free from any form of restraint, seclusion as a means of coercion, discipline, inconvenience or retaliation as specified in other federal regulations on the use of restraints and seclusion
• Decide ahead of time regarding the kinds of care they want if they become sick, injured or seriously ill by making a living will
• Expect their records (including medical and personal information) and communications will be treated confidentially
• If under age 18 and married, pregnant or have a child, be able to make decisions about his or her own health care and/or his or her child’s health care
• Choose their PCP from the Wellpoint network of providers
• Make a complaint to Wellpoint and get a response within 30 days
• Have information about Wellpoint, its services, practitioners, and provider and member rights and responsibilities
• Receive information on the Notice of Privacy Practices as required by the Health Insurance Portability and Accountability Act (HIPAA)
• Get a current member handbook and a directory of health care providers within the Wellpoint network
• Choose any Wellpoint network specialist
• Change their doctor to another Wellpoint network doctor if the doctor is unable to refer them to the Wellpoint network specialist of their choice
• Be connected to health care providers for ongoing treatment of chronic disabilities
• Have access to their PCP or a backup 24 hours a day, 365 days a year for urgent or emergency care
• Receive care right away from any hospital when their medical condition meets the definition of an emergency
• Receive post-stabilization services following an emergency condition in some situations
• Call the Wellpoint toll-free, 24-hour Nurse HelpLine. English: 1-866-864-2544; Spanish: 1-866-864-2545
• Call the Wellpoint toll-free Member Services telephone line from 8 a.m. to 6 p.m. Eastern time, Monday to Friday
• Know what payment methodology Wellpoint utilizes with health care providers
• Receive assistance in filing a grievance and/or appeal and appeal through the Wellpoint internal system
• File a grievance or appeal if he or she is not happy with the results of a grievance and receive acknowledgement within 10 days and a resolution within 30 days
• Ask Wellpoint to reconsider previously denied coverage; upon receipt of the member’s medical information, Wellpoint will review the request
• Freely exercise the right to file a grievance or appeal such that exercising of these rights will not adversely affect the way the member is treated
• Receive notification to present supporting documentation for their appeal
• Examine files before, during and after their appeal
• Request an administrative hearing when dissatisfied with the Wellpoint decision
• Continue to receive benefits pending the outcome of an appeal decision or state administrative hearing if the appropriate rules are followed
• Only be responsible for cost-sharing in accordance with 42 CFR 447.50-42 CFR 447.60 and Maryland provisions for Medicaid
• To make recommendations regarding the Wellpoint Rights and Responsibilities Policy

Members have the responsibility to:

• Treat their providers, their providers’ staff and Wellpoint employees with respect and dignity
• Not behave in a disruptive manner while in the provider’s office
• Respect the rights and property of all providers
• Cooperate with people providing health care
• Tell their PCP about their symptoms and problems and ask questions
• Get information and consider treatments before they are performed
• Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible
• Discuss anticipated problems with following their provider’s directions
• Consider the outcome of refusing treatment recommended by a provider
• Follow plans and instructions for care they have agreed on with their providers, to the best of their ability
• Help their provider obtain medical records from the previous provider and help their provider complete new medical records as necessary
• Supply information (to the extent possible) the organization and its practitioners and providers need to provide care
• Respect the privacy of other people waiting in providers’ offices
• Call Wellpoint and change their PCP before seeing a new PCP
• Make and keep appointments and arrive on time; members should always call if they need to cancel an appointment, change an appointment time or if they will be late
• Discuss complaints, concerns and opinions in an appropriate and courteous way
• Tell their provider how they want to receive their health information
• Obtain medical services from their PCP
• Learn and follow the Wellpoint policies outlined in the member handbook
• Read the member handbook to understand how Wellpoint works
• Notify Wellpoint when a member or family member who is enrolled in Wellpoint has died
• Become involved in their health care and cooperate with their provider about recommended treatment
• Learn the correct method by which his or her medications should be taken
• Carry his or her Wellpoint ID card at all times and quickly report any lost or stolen cards to Wellpoint; members should contact Wellpoint if information on the ID card is wrong or if there are changes to their name, address or marital status.
• Show their ID cards to each provider
• Tell Wellpoint about any providers they are currently seeing
• Provide true and complete information about their circumstances
• Report change(s) in their circumstances
• Notify his or her PCP as soon as possible after they receive emergency services
• Go to the emergency room only when they have an emergency
• Report suspected fraud and abuse