Treat all Members with respect and courtesy, as you would want yourself or your loved ones to be treated.
Respond promptly to Members’ questions and document communications with Members as appropriate.
Protect the rights of Members by publicizing such rights to Members, Community employees, and network Providers.
Comply with all the legal and professional standards of care, ethics, conduct and behavior applicable to health maintenance organizations, their employees, and their network Providers.
Provide all Members with information concerning the benefits available to them so that they may avail themselves of such benefits as appropriate.
Ensure that Members have reasonable access to the services to which they are entitled under their health plan.
Assist Members (or their legal guardians, when appropriate) with making informed decisions about their medical care, including providing them with information about withholding resuscitative services, foregoing or withdrawing life-sustaining treatment, or participating in studies or clinical trials. Providers, as required by law, shall obtain informed consent.
Preserve the integrity and independence of clinical decision-making by individual Providers in the Community Provider Network. In making clinical decisions concerning a Member’s medical care, a Community Network Provider shall not allow himself/herself to be influenced by how the Provider or Provider network is financially compensated or by whether a particular treatment or course of care would be covered by the Member’s plan. In conveying information concerning whether a particular treatment is covered by a Member’s plan, no Community employee shall attempt to influence the Provider’s clinical decision with respect to the Member’s need for such treatment.
Avoid conflicts of interest. Network Providers making clinical decisions concerning a Member’s medical care and Community employees making administrative decisions concerning a Member’s coverage should not be influenced by any financial interest they may have in any entity to which the Member has been or may be referred.
Maintain the confidentiality, as required by law, of information concerning Members’ medical care and health status.
Promote the wellbeing of Members by developing and making preventive healthcare programs and health education materials available to Members.
Maintain an internal grievance and complaint resolution procedure whereby Member complaints and grievances about network Providers, the quality of care, Community services or coverage decisions may be heard and resolved. Each Member shall be provided sufficient information to allow access to the complaint and grievance resolution process.