Provider Manual


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 Member Handbook, please call the toll-free provider line at 877-615-8503.

As stated in the Carelon Member Handbook, members, their family members, and/or legal guardians have a right to:

  1. Be treated with dignity and respect;
  2. Have their medical records and conversations with service providers kept private;
  3. Take part in decisions about their care, including the right to refuse treatment;
  4. Receive information on available treatment options and alternatives;
  5. Have the treatment plan and the possible risks explained;
  6. Help set up the treatment plan;
  7. Ask for a change in the treatment plan;
  8. Be free from any form of restraint or seclusion during treatment used as a means of coercion, discipline, convenience, or retaliation;
  9. Choose a provider from a list of HealthChoices program providers;
  10. Request a copy of their medical record from their provider;
  11. Review their medical records and talk about them with their provider;
  12. Change their provider;
  13. Ask their provider, or any person who is helping them, about his or her qualifications;
  14. Request a copy of information maintained by Carelon (Carelon information may include claims and authorization information, complaints, referrals, disclosures and other documented contact they or their provider have had with us.);
  15. Request to amend the Carelon information listed above in order to correct any errors (The decision to make an amendment is made by the Carelon Medical Director.);
  16. Receive services without regard to race, color, religion, sex, sexual orientation, age or ethnic background;
  17. File a complaint or grievance about their care or the services they receive;
  18. Ask for the help of an ombudsman to help file a complaint or grievance;
  19. Talk with a Consumer Satisfaction Team (CST) staff person about the quality of their services;
  20. Ask for the help of an advocate;
  21. Ask for a copy of the Medical Necessity Criteria;
  22. Freely exercise their rights, and that exercising those rights will not affect how they are treated by their provider or Carelon.

The Member Handbook also states members, their family members, and/or legal guardians are responsible for:

  • Treating the people giving them care with dignity and respect;
  • Giving their provider the information that he or she needs to better serve them;
  • Helping their provider understand their health problems;
  • Working with their provider to help develop a treatment plan;
  • Asking their provider questions so that they understand their treatment plan;
  • Following the treatment plans that they have developed and agreed to with their provider;
  • Keeping appointments with their provider;
  • Contacting their provider to cancel or re-schedule an appointment;
  • Notifying their provider if they decide to stop treatment;
  • Notifying their Member and Provider Service Representative if they move or change their address/phone number.