Overview
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Members have the right to expect a certain level of service from their health care providers. Members are also responsible for cooperating with providers in obtaining health care services. These member rights and responsibilities apply to members' relationships with Health Net, and all participating providers responsible for member care.
Health Net members are notified of their rights and responsibilities via the annual member mailing and the Evidence of Coverage (EOC). The following text is taken directly from the Health Net Medi-Cal member's handbook.1
Health Net members have these responsibilities:
- Act courteously and respectfully. You are responsible for treating your doctor and all providers and staff with courtesy and respect. You are responsible for being on time for your visits or calling your doctor's office at least 24 hours before the visit to cancel or reschedule.
- Give up-to-date, accurate and complete information. You are responsible for giving correct information and as much information as you can to all of your providers, and to Health Net. You are responsible for getting regular check-ups and telling your doctor about health problems before they become serious.
- Follow your doctor's advice and take part in your care. You are responsible for talking over your health care needs with your doctor, developing and agreeing on goals, doing your best to understand your health problems, and following the treatment plans and instructions you both agree on.
- Use the emergency room only in an emergency. You are responsible for using the emergency room in cases of an emergency or as directed by your doctor. Emergency care is a service that you reasonably believe is necessary to stop or relieve sudden serious illnesses or symptoms, and injury or conditions requiring immediate diagnosis and treatment.
- Report wrong-doing. You are responsible for reporting health care fraud or wrong-doing to Health Net Community Solutions. You can do this without giving your name by calling Health Net Fraud and Abuse Hotline toll-free at 866-685-8664. The Fraud Hotline operates 24 hours a day, seven days a week. All calls are strictly confidential.
Health Net members have these rights:
- To be treated with respect and dignity, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information.
- To be provided with information about the health plan and its services, including covered services, practitioners, and member rights and responsibilities.
- To get fully translated written member information in your preferred language, including all grievance and appeals notices.
- To make recommendations about Health Net’s member rights and responsibilities policy.
- To be able to choose a primary care provider within Health Net's network.
- To have timely access to network providers.
- To participate in decision making with providers regarding your own health care, including the right to refuse treatment.
- To voice grievances, either verbally or in writing, about the organization or the care you got.
- To know the medical reason for Health Net’s decision to deny, delay, terminate or change a request for medical care.
- To get care coordination.
- To ask for an appeal of decisions to deny, defer or limit services or benefits.
- To get no-cost interpreting services for your language.
- To get free legal help at your local legal aid office or other groups.
- To formulate advance directives.
- To ask for a State Hearing if a service or benefit is denied and you have already filed an appeal with Health Net and are still not happy with the decision, or if you did not get a decision on your appeal after 30 days, including information on the circumstances under which as expedited hearing is possible.
- To disenroll (drop) from Health Net and change to another health plan in the county upon request.
- To access minor consent services.
- To get no-cost written member information in other formats (including braille, large-size print, audio format and accessible electronic formats) upon request and in a timely fashion appropriate for the format being requested and in accordance with Welfare and Institutions (W&I) Code section 14182 (b)(12).
- To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
- To truthfully discuss information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand, regardless of cost or coverage.
- To have access to and get a copy of your medical records, and request that they be amended or corrected, as specified in 45 Code of Federal Regulations (CFR) §164.524 and 164.526.
- Freedom to exercise these rights without adversely affecting how you are treated by Health Net, your providers or the state.
- To have access to family planning services, Freestanding Birth Centers, Federally Qualified Health Centers, Indian Health Clinics, midwifery services, Rural Health Centers, sexually transmitted infection services and emergency services outside Health Net’s network pursuant to the federal law.
- To request an Appeal of an adverse benefit determination within 60 calendar days from the date on the Notice of Adverse Benefit Determination (NABD) and request how to continue benefits during the in-plan appeal process through the State Fair Hearing, when applicable.
CalViva Health members have these responsibilities:
- Act courteously and respectfully. You are responsible for treating your doctor and all providers and staff with courtesy and respect. You are responsible for being on time for your visits or calling your doctor's office at least 24 hours before the visit to cancel or reschedule.
- Give up-to-date, accurate and complete information. You are responsible for giving correct information and as much information as you can to all of your providers, and to our plan. You are responsible for getting regular check-ups and telling your doctor about health problems before they become serious.
- Follow your doctor's advice and take part in your care. You are responsible for talking over your health care needs with your doctor, developing and agreeing on goals, doing your best to understand your health problems, and following the treatment plans and instructions you both agree on.
- Use the emergency room only in an emergency. You are responsible for using the emergency room in cases of an emergency or as directed by your doctor. Emergency care is a service that you reasonably believe is necessary to stop or relieve sudden serious illnesses or symptoms, and injury or conditions requiring immediate diagnosis and treatment.
- Report wrong-doing. You are responsible for reporting health care fraud or wrong-doing to CalViva Health. You can do this without giving your name by calling the CalViva Health Fraud and Abuse Hotline toll-free at 866-863-2465.
CalViva Health members have these rights:
- To be treated with respect and dignity, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information.
- To be provided with information about the plan its services, including Covered Services practitioners, and member rights and responsibilities.
- To receive fully translated written member information in your preferred language, including all grievance and appeals notices.
- To make recommendations about CalViva Health’s member rights and responsibilities policy.
- To be able to choose a primary care provider within CalViva Health's network.
- To have timely access to network providers.
- To participate in decision making with providers regarding your own health care, including the right to refuse treatment.
- To voice grievances, either verbally or in writing, about the organization or the care you got.
- To know the medical reason for CalViva Health’s decision to deny, delay, terminate or change a request for medical care.
- To get care coordination.
- To ask for an appeal of decisions to deny, defer or limit services or benefits.
- To get no-cost interpreting services for your language.
- To get free legal help at your local legal aid office or other groups.
- To formulate advance directives.
- To ask for a State Hearing if a service or benefit is denied and you have already filed an appeal with CalViva Health and are still not happy with the decision, or if did not get a decision on your appeal after 30 days, including information on the circumstances under which an expedited hearing is possible.
- To disenroll from CalViva Health and change to another health plan in the county upon request.
- To access minor consent services.
- To get no-cost written member information in other formats (including braille, large-size print, audio and accessible electronic formats) upon request and in a timely fashion appropriate for the format being requested and in accordance with Welfare & Institutions Code Section 14182 (b)(12).
- To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
- To truthfully discuss information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand, regardless of cost or coverage.
- To have access to and get a copy of your medical records, and request that they be amended or corrected, as specified in 45 Code of Federal Regulations §164.524 and 164.526.
- Freedom to exercise these rights without adversely affecting how you are treated by CalViva Health, your providers or the State.
- To have access to family planning services, Freestanding Birth Centers, Federally Qualified Health Centers, Indian Health Clinics, midwifery services, Rural Health Centers, sexually transmitted infection services and emergency services outside CalViva Health’s network pursuant to the federal law.
Community Health Plan of Imperial Valley (CHPIV) members have these rights:
- To be treated with respect and dignity, giving due consideration to your right to privacy and the need to maintain confidentiality of your medical information.
- To be provided with information about the health plan and its services, including covered services, practitioners, and member rights and responsibilities.
- To get fully translated written member information in your preferred language, including all grievance and appeals notices.
- To make recommendations about Community Health Plan of Imperial Valley’s member rights and responsibilities policy.
- To be able to choose a primary care provider within Community Health Plan of Imperial Valley ‘s network.
- To have timely access to network providers.
- To participate in decision making with providers regarding your own health care, including the right to refuse treatment.
- To voice grievances, either verbally or in writing, about the organization or the care you got.
- To know the medical reason for the Plan’s decision to deny, delay, terminate or change a request for medical care.
- To get care coordination.
- To ask for an appeal of decisions to deny, defer or limit services or benefits.
- To get no-cost interpreting and translation services for your language.
- To get free legal help at your local legal aid office or other groups.
- To formulate advance directives.
- To ask for a State Hearing if a service or benefit is denied and you have already filed an appeal with the Plan and are still not happy with the decision, or if did not get a decision on your appeal after 30 days, including information on the circumstances under which an expedited hearing is possible.
- To disenroll (drop) from Community Health Plan of Imperial Valley and change to another health plan in the county upon request.
- To access minor consent services.
- To get no-cost written member information in other formats (such as braille, large-size print, audio and accessible electronic formats) upon request and in a timely fashion appropriate for the format being requested and in accordance with Welfare and Institutions Code (W&I) section 14182 (b)(12).
- To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
- To truthfully discuss information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand, regardless of cost or coverage.
- To have access to and get a copy of your medical records, and request that they be amended or corrected, as specified in 45 Code of Federal Regulations (CFR) sections §164.524 and 164.526.
- Freedom to exercise these rights without adversely affecting how you are treated by the Plan, your providers or the state.
- To have access to family planning services, Freestanding Birth Centers, Federally Qualified Health Centers, Indian Health Clinics, midwifery services, Rural Health Centers, sexually transmitted infection services and emergency services outside the Plan’s network pursuant to the federal law.
- To request an Appeal of an Adverse Benefit Determination within 60 calendar days from the date on the Notice of Adverse Benefit Determination (NABD) and request how to continue benefits during the in-plan appeal process through the State Fair Hearing, when applicable.
CHPIV members have these responsibilities:
- Act courteously and respectfully. You are responsible for treating your doctor and all providers and staff with courtesy and respect. You are responsible for being on time for your visits or calling your doctor's office at least 24 hours before the visit to cancel or reschedule.
- Give up-to-date, accurate and complete information. You are responsible for giving correct information and as much information as you can to all of your providers, and to our plan. You are responsible for getting regular check-ups and telling your doctor about health problems before they become serious.
- Follow your doctor's advice and take part in your care. You are responsible for talking over your health care needs with your doctor, developing and agreeing on goals, doing your best to understand your health problems, and following the treatment plans and instructions you both agree on.
- Use the emergency room only in an emergency. You are responsible for using the emergency room in cases of an emergency or as directed by your doctor. Emergency care is a service that you reasonably believe is necessary to stop or relieve sudden serious illnesses or symptoms, and injury or conditions requiring immediate diagnosis and treatment.
- Report wrong-doing. You are responsible for reporting health care fraud or wrong-doing to the Plan. You can do this without giving your name by calling the Fraud and Abuse Hotline toll-free at 866-685-8664.
1 The actual statements of member rights and responsibilities are in accordance with the National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS) and may vary slightly from what is listed. In addition to member rights and responsibilities, medical services must be provided in a culturally competent manner without regard to race, color, national origin, creed, ancestry, religion, language. sex, marital status, sexual orientation, gender identity, age, health status, physical or mental disability, or any identification with any other persons or groups defined in Penal Code 422.56.