Utilization Management Affirmative Statement

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Heritage Sierra Medical Group does not give financial incentives for UM decision makers and does not encourage denials of coverage or service. Providers may freely communicate with patients about their treatment, regardless of benefit coverage limitations.

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Members’ Rights

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Members have rights and associated responsibilities in the course of their health care service delivery. All contracted health plans have formal statements of member rights and responsibilities. The following represents some of the rights a member has:

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• Be treated with dignity and respect.

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• Exercise these rights without regard to gender, sexual orientation or cultural, economic, educational, disability status, or religious background.

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• Be provided with information about Heritage Sierra Medical Group, its services, and the health care service delivery process.

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• Be informed of non-emergent cost of care and receive an explanation of the member's financial obligations as appropriate, prior to incurring the expense (including co-payments, deductibles, and co-insurance)

• Examine and receive an explanation of bills generated for services delivered to the member and payable by member (e.g. non-covered services).

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• Have 24-hour access to the member's primary care physician (or covering physician).

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• Receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, and prospects for recovery in terms that are understandable to the member, in order to give informed consent or to refuse that course of treatment.

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• Actively participate in decisions regarding the member's health care and treatment plan, regardless of cost or benefit coverage. To the extent permitted by law, this includes the right to refuse any procedure or treatment. If the recommended procedure or treatment is refused, and explanation will be given addressing the effect that this will have on the member's health.

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• Receive reasonable continuity of care and be given timely and sensible responses to questions and requests made for service.

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• Voice complaints or appeals about Heritage Sierra Medical Group or the care it provides.

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• Members have the right to be represented by parents, guardians, family members or other conservators for those who are unable to fully participate in their treatment decisions.

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• Make recommendations regarding Heritage Sierra Medical Group members' rights and responsibilities policies.

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• Upon request, utilization management criteria used to authorize, modify, or deny health care services are available to the public.

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Members’ Responsibilities

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The following represents some of the responsibilities a member has:

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• Be familiar with the benefits and exclusions of the member's health plan coverage.

• Provide the member's health care provider with complete and accurate information, which is necessary for the care of the member (to the extent possible).

• Be on time for all appointments and notify the provider's office as far in advance as possible for appointment cancellation and rescheduling.

• Report changes in the member's condition according to provider instructions.

• Inform providers of the member's inability to understand information given to him/her.

• Treat the health care providers and staff with respect and dignity.

• Contact the member's primary care physician (or covering physician) for any care, which is needed after that physician's normal office hours.

• Obtain an authorized referral from the member's primary care physician for a visit to a specialist and/or to receive any specialty care.

• Follow the treatment plan, which has been developed and agreed upon by the health care provider and member, and understand the health problems and participate in developing mutually agreed upon treatment goals to the degree possible.

• Be familiar and comply with Heritage Sierra Medical Group's health care service delivery system regarding questions and assistance.

• Respect the rights, property, and environment of all physicians and Heritage Sierra Medical Group providers, staff, and other members.

• Pay required co-payment or co-insurance amounts.

• Choose an Advance Directive to designate the kind of care you wish to receive should you be unable to express your wishes.

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UM Criteria

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Heritage Sierra Medical Group's Utilization Management review process uses a wide range of criteria, guidelines and reference tools to assist determination of benefit coverage and medical appropriateness. Supporting clinical information, relevant to each particular case is reviewed when making medical necessity coverage determination.

Heritage Sierra Medical Group requires that physicians and health care professionals make medical decisions based on medical needs of members. We do not compensate anyone for denying coverage or service, and we do not use financial incentives to encourage denials of any needed medical service. To prevent inappropriate decision making, Heritage Sierra Medical Group/HPN monitors for under- and over-utilization by analyzing data to identify causes and then takes actions to correct any instances of potential or actual under- or over-utilization.

 

California Language Assistance Program

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Health Insurance Plans provide their members who have Limited English Proficiency (LEP) access to both written and spoken language assistance.

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Heritage Sierra Medical Group can assist you in obtaining interpreter services while in the medical or clinical setting, helping to enhance the communication and health care experience for our member.