2015 Dear Patient; MEMBER WELCOME GUIDE The staff of Scripps Health Plan and its affiliate Plan Medical Groups (PMG), Scripps Clinic Medical Group, Scripps Coastal Medical Center, Mercy Physician Medical Group, Primary Care Associates Medical Group and Scripps Physician Medical Group would like to take this opportunity to thank you for choosing Scripps Health Plan to be your partners in good health. We at Scripps Health Plan are committed to providing quality health care and excellent customer service to all of our members. This Member Welcome Guide is intended to assist you with questions you may have regarding access to health care services. We also encourage you to read the Evidence of Coverage and Summary of Benefits. HMO means "Health Maintenance Organization." HMO plans offer a wide range of healthcare services through a network of providers who agree to supply services to members on a prepaid basis. Primary care physicians (PCPs) and their affiliated plan medical group (PMG) assume responsibility for your care and coordinate all medically necessary services. HMOs are regulated by the Department of Managed Healthcare who monitor care, quality, patient access, provider compliance, and financial solvency of California health plans The Role of your Primary Care Physician If you are new to an HMO, you may not have chosen a Primary Care Physician (PCP) in the past. It is important to understand the role your PCP will play in your health care. With few exceptions, your PCP is responsible for providing or arranging all your health care needs, referrals to specialists and authorizations for hospitalization or outpatient treatment. The primary care providers affiliated with Scripps Health Plan include Family Practice, Internal Medicine, Pediatric and OBGYN. If you have not yet chosen a PCP, we recommend that you do so immediately, and arrange an appointment to meet with him or her within your first 90 days of becoming effective with Scripps Health Plan. Just call the Customer Service Department at your HMO and they will assist you with your choice. If you have any questions about the physicians affiliated with Scripps Health Plan, please feel free to contact our Customer Service Department toll free at 1-844-337-3700 or TTY at 1-888-515-4065 for the hearing and speech impaired. Your health care needs are important to Scripps. Be sure to make your annual 10790 Rancho Bernardo Road Mail Drop: 4S-300 San Diego, CA 92127, 1 (844) 337-3700
appointment for your preventative services such as your annual physical. Your Primary Care Physician will provide all routine medical care. This way, your physician learns your individual medical history and assists you in developing a health care program to fit your lifestyle and medical needs. Specialty Care Your Primary Care Physician is most qualified to ensure that you are receiving all the care that is medically indicated for you. He or she will coordinate all referrals to specialists and work with the specialist to develop the most appropriate treatment plan for you. In most cases the specialist will be a provider associated with SHPS. There may be cases when the type of specialist you require is not available within our network. Should that occur, your PCP would work with the Utilization Management Department to obtain an authorization to the type of specialist you need. Referrals Referrals to specialists must be coordinated by your Primary Care Physician in order for the service to be covered. The exception is urgent/emergent care when you are unable to safely contact your doctor before seeking care. All other nonurgent/non-emergent services (such as elective surgeries, radiology, home health services, physical therapy and durable medical equipment) require prior authorization. The standard for emergent authorization is final decision being made no later than 72 hours after receipt of the request. The standard for obtaining a prior authorization is no later than 5 business days after receipt of the request. This standard is from the time all medical information is available to make a determination. Additional time may be needed to actually get an appointment with the specialist or arrange for other healthcare services. Your primary care physician will coordinate all requests for you and will be able to give you status of your referral/authorization request. Scripps Health Plan Services' Utilization Management decision making is based on appropriateness of care and service; does not compensate practitioners or individuals for denials and does not offer incentives to encourage denials. Utilization Management team hours of operations are Monday Friday from 8 a.m. 5 p.m. Information Regarding Policies and Review Guidelines You have the right to request information on the operational policies and clinical review criteria used by Scripps Health Plan to coordinate your healthcare needs. You may obtain a free of charge copy of the actual benefit provision, guideline, protocol or other similar criterion on which the denial decision was based, upon request, by calling Scripps Health Plan at 1-844-337-3700 or TTY at 1-888-515-4065 for the hearing and speech impaired. EMERGENCY AND URGENT CARE SERVICES Emergency Services Emergency Services and Care is defined as A medical condition that manifests Page 2 of 8
itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) placing your health as the patient in serious jeopardy; (2) serious impairment to your bodily functions; or (3) serious dysfunction to any of your bodily organs or parts. In case of a true emergency, call 911 or go directly to the nearest facility for treatment. Should you be admitted to the hospital following emergency care, please call your doctor or have a family member call as soon as reasonably possible. Remember that your primary doctor knows your medical history best. Your primary care physician or a designated covering physician will be available to you twenty-four hours a day. When you need care after hours, on weekends or on holidays, always try to call your doctor first. He or she will be able to direct you to the most appropriate place for treatment. Urgent Care Services Unforeseen injuries or illnesses that require medical attention within a short time frame (usually 24 hours) but which are not life threatening are considered Urgent Care Services. When an urgent situation occurs, please do the following: 1. Call your Primary Care Physician for instructions. 2. If you are calling during non-business hours and reach an answering service, ask the operator to page your physician or the physician on call. When you receive a return call, explain the situation and follow the physician s instructions. 3. If you are unable to reach your Primary Care Physician, follow the instructions under Emergencies Member Rights and Responsibilities As an HMO member you have both rights and responsibilities. You are responsible for keeping appointments, making your co-payments, for knowing the benefits administered by Scripps Health Plan as outlined in your Evidence of Coverage. You are responsible for conducting yourself in a non-confrontational manner when dealing with challenging situations. You are responsible for contacting your PCP to coordinate all your care through him or her including following through with recommended treatment plans. Scripps Health Plan has included a Member Bill of Rights and Responsibilities with your Evidence of Coverage. Please read it carefully. In addition, Scripps Health Plan has attached a copy of our Member Rights and Responsibilities to this packet for your review. Whenever you are dissatisfied with the care or treatment you receive, or with a denied service or benefit or other concerns, you have the right to file a complaint. To do so, call Scripps Health Plan Customer Service Department at 1-844-337-3700 or TTY/TDD at 1-888- 515-4065 for the hearing and speech impaired between the hours of 8 a.m. and 5 p.m. Monday through Friday. We will send a written acknowledgement letter of your grievance within five (5) days, and a final decision letter within thirty (30) days. You have the right to an expedited appeal if you feel that waiting for Page 3 of 8
the standard appeal time (30 days) could seriously harm your health or ability to function. You may request an expedited appeal for reasons including, but not limited to, severe pain, or potential loss of life, limb or major bodily function. The request may be initiated by you or by your physician; we will provide you with a decision within seventy two (72) hours. You have at least one hundred and eighty (180) calendar days to file a verbal, written or online complaint of your dissatisfaction. How to File a Grievance Before filing a Grievance if you have a question or a concern Customer Service at Scripps Health Plan will be able to assist you by calling 1-844-337-3700 or TTY/TDD at 1-888-515-4065 (for the hearing and speech impaired). If your issue cannot be resolved to your satisfaction, you may file a grievance. If you wish, your grievance may be submitted verbally, telephonically, online at www.scrippshealth.com or in writing via facsimile at 858-260-5879 or mail at the address noted below. A grievance form can be provided to you, a grievance form is available online at www.scrippshealthplan.com or you may simply write a letter. Send your grievance letter to: Scripps Health Plan Attention: Appeals & Grievances Mail Drop: 4S-300 10790 Rancho Bernardo Road San Diego, California 92127 Expedited Appeals If a requested service has been denied, you have the right to an expedited appeal if you feel that waiting for the standard appeal time (30 business days) could seriously harm your health or ability to function. You may request an expedited appeal for reasons including, but not limited to, severe pain, or potential loss of life, limb or major bodily function. The request may be initiated by you or by your physician. Call the Customer Service Department at 1-844- 337-3700 or TTY at 1-888-515-4065 (for the hearing and speech impaired and tell the representative that a requested service has been denied and you are asking for an expedited appeal. Your physician may call Customer Service Department at 1-844-337-3700. You may expect a decision in no more than 72 hours. You may also expect a written confirmation of the decision within 2 working days of the initial notification. Department of Managed Health Care Complaint Process The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-844-337-3700 or TTY/TDD at 1-888- 515-4065 (for the hearing and speech impaired) and use your health plan s Page 4 of 8
grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. You may have the right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act (ERISA) if you are enrolled with your health plan through an employer who is subject to ERISA. First, be sure that all required reviews of your claim appeal have been completed and your claim has not been approved. Then consult with your employer's benefit plan administrator to determine if your employer s benefit plan is governed by ERISA. Additionally, you and your health plan may have other voluntary alternative dispute resolution options, such as mediation. *Federal Employee Health Benefit Program (FEHBP) members: The preceding appeals information does not apply to participants of the FEHBP. If you are covered by the FEHBP, please refer to Section 8, The Disputed Claims Process, of your Federal Brochure, which explains the FEHBP appeals process. Other resources to help you: For plans covered by the health care reform law Employee Benefits Security Administration 1-866-444-EBSA (3272) California Department of Managed Health Care HMO Help Center Toll Free: 1-888-HMO-2219 TDD/TTY 1-877-688-9891 http://www.healthhelp.ca.gov. In Summary We are very pleased to have you as a member of our medical family. Scripps Health Plan is committed to providing quality care and we know that by working together this can be achieved to everyone s good health! Sincerely, Page 5 of 8
Scripps Health Plan Customer Service Department Phone: 1-844-337-3700 TTY: 1-888-515-4065 MEMBERS RIGHTS AND RESPONSIBILITIES Scripps Health Plan is committed to treating members in a manner that respects their rights. Also, Scripps Health Plan has certain expectations of members responsibilities. Both these commitments will be upheld at all times by all staff in all activities. As a patient, you have the right to: 1. Receive considerate and respectful care, and be made comfortable. You have the right to have your cultural, psychosocial, spiritual, and personal values, beliefs and preferences respected. 2. Have notification of your admission to a hospital sent promptly to a family member (or other representative of your choosing) and your own physician. 3. Know the name of the physician who has primary responsibility for coordinating your care and the names and professional relationships of other physicians and non-physicians who will see you. 4. Receive information about your health status, diagnosis, prognosis, treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life-sustaining treatment. 5. Make decisions regarding your medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment. 6. Request or refuse treatment, to the extent permitted by law. However, you do not have the right to demand inappropriate or medically unnecessary Page 6 of 8
treatment or services. You have the right to leave the facility even against the advice of physicians, to the extent permitted by law. 7. Be told about any human experimentation that the facility or your personal physician proposes to engage in that might affect your care or treatment. You have the right to refuse to participate in such research projects. 8. Reasonable responses to any reasonable requests made for service. 9. Appropriate assessment and management of your pain, and to be given information about pain and pain relief measures. You have the right to participate in decisions about your pain management. You may request or reject the use of any or all modalities to relieve pain, including opiate medication, if you suffer from severe chronic intractable pain. The doctor may refuse to prescribe the opiate medication, but if so, must inform you that there are physicians who specialize in the treatment of severe chronic intractable pain with methods that include the use of opiates. 10. Formulate advance directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Staff and practitioners who provide care will comply with these directives. All patients' rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf. 11. Respect for your personal privacy. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be told the reason for the presence of any individual. You have the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms. 12. Confidential treatment of all communications and records pertaining to your care l. You will receive a separate "Notice of Privacy Practices" that explains your privacy rights in detail and how Scripps Health may use and disclose your protected health information. 13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying government agencies of neglect or abuse. 14. Freedom from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff. 15. Reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of the persons providing the care. Page 7 of 8
16. Be informed by the physician, or a delegate of the physician, of continuing health care requirements and options following discharge. You have the right to be involved in the development and implementation of your discharge plan. Upon your request, a friend or family member may be provided this information also. 17. Know which rules and policies apply to your conduct while a patient. 18. Designate visitors/support individuals of your choosing if you have decision-making capacity, whether or not the individual is related by blood or marriage, unless: o No visitors are allowed. o The facility reasonably determines that the presence of a particular visitor would endanger the health or safety of a patient, a staff member of the health facility staff or other visitor to the health facility, or would significantly disrupt the operations of the facility. o You have told the health facility staff that you no longer want a particular person to visit. o However, a health facility may establish reasonable restrictions upon visitation, including restrictions upon the hours of visitation and number of visitors. 19. Have your wishes considered, if you lack decision-making capacity, for the purposes of determining who may visit. The method of that consideration will be disclosed in the hospital policy on visitation. At a minimum, the hospital shall include any persons living in your household. 20. Examine and receive an explanation of your bill regardless of the source of payment. Page 8 of 8