제공자 매뉴얼

회원의 권리와 책임

It is the policy of Carelon to ensure that members are treated in a manner that respects their rights and responsibilities as members. Providers are required to inform Carelon members under their care of these rights and responsibilities. Member rights and responsibilities must be either distributed directly to the members or posted in an area visible to them. To obtain a copy of the 회원 핸드북, please call the toll-free provider line at 1-877-615-8503.

As stated in the Carelon 회원 핸드북, 회원, 그 가족 및/또는 법적 보호자는 다음과 같은 권리가 있습니다.

It is the policy of Carelon to ensure that members are treated in a manner that respects their rights and responsibilities as members. Providers are required to inform Carelon members under their care of these rights and responsibilities. Member rights and responsibilities must be either distributed directly to the members or posted in an area visible to them. To obtain a copy of the 회원 핸드북, 수신자 부담 전화 877-615-8503으로 전화하십시오.

As stated in the Carelon 회원 핸드북—members, their family members, and/or legal guardians have a right to:

1. Be treated with dignity and respect, recognizing member dignity and need for privacy by Carelon staff and network providers;
2. Get information that members can easily understand about Carelon, its services and the providers that treat members
3. Pick any Carelon network providers that members want to treat them. Members can change providers if they are unhappy.
4. Get emergency services when needed from any provider without Carelon’s approval
5. Get information that members can easily understand from their providers and be able to talk to them about their treatment options, risks of treatment and tests that may be self-administered without any interference from Carelon

1.   Make decisions about their treatment. If a member cannot make treatment decisions by themselves, they have the right to have someone else help them make decisions or make decisions for them. Members may refuse treatment or services unless they are required to get involuntary treatment under the Mental Health Procedures Act.
2.    Talk with providers in confidence and to have member information and records kept confidential.
3. See and get a copy of their medical records and to ask for changes or corrections to their records.
4. Ask for a second opinion
5. File a Grievance if a member disagrees with Carelon’s decision that a service is not medically necessary for the member.
6. File a Complaint if a member is unhappy about the care or treatment received.
7. Ask for a Department of Human Services Fair Hearing
8. Be free from any form of restraint or seclusion used to force a member to do something, to discipline a member, or to make it easier for the provider, or to punish a member.
9. Get information about services that Carelon or a provider does not cover because of moral or religious objections and about how to get those services
10. To exercise member rights without it negatively affecting the way the Department of Human Services, Carelon, or network providers treat members.
11. Create Advance Directives.
12. Make recommendations about the rights and responsibilities of Carelon’s members.

그만큼 회원 핸드북 also states members, their family members and/or legal guardians are responsible for:

• Provide, to the extent they can, information needed by their providers
• Tell providers what medications they are taking, including over-the-counter medicines, vitamins and natural remedies.
• Be involved in decisions about their health care and treatment
• Work with their providers to create and carry out their treatment plans
• Tell their providers what they want and need
• Take their medications as prescribed and tell their provider if there is a problem
• Keep their appointments
• Learn about Carelon’s coverage, including all covered and non-covered benefits and limits
• Use only network providers unless Carelon approves an out-of-network provider
• Respect other patients, provider staff, and provider workers
• Report fraud and abuse to the Department of Human Services Fraud and Abuse Reporting Hotline