Quality Management
Member Rights & Responsibilities

Commercial and Medicare Member Rights and Responsibilities Statements

Commercial Member Rights:

  • The member has the right to information about the health plan, its benefits, services included or excluded from coverage policies, participating practitioners/providers and members’ rights and responsibilities. Written and Web-based information that is provided to the member will be readable and easily understood.
  • The member has the right to be treated with respect, and recognition of their dignity and right to privacy.
  • The member has the right to participate in decision making regarding his/her health care. This right includes candid discussions of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage.
  • The member has a right to voice complaints or appeals about the health plan or care provided, and to receive a timely response. The member has a right to be notified of the disposition of appeals/complaints and the right to further appeal, as appropriate.
  • The member has the right to make recommendations regarding the organization’s member rights and responsibilities policies by contacting the Member Services Department in writing.
  • The member has the right to confidential treatment of personally identifiable health/medical information. The member also has the right to have access to his/her medical record in accordance with applicable Federal and state laws.
  • The member has the right to reasonable access to medical services.
  • The member has the right to receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, genetic information, color, religion, gender, national origin or source of payment.
  • The member has the right to formulate advance directives. The Plan will provide information concerning advance directives to members and practitioners and will support members through its medical record keeping policies.
  • The right to obtain a current directory of participating practitioners in the plan’s network, upon request. The directory includes addresses, telephone numbers and a listing of providers who speak languages other than English.
  • The right to file a complaint or appeal about the health plan or care provided with the applicable regulatory agency and to receive an answer to those complaints within a reasonable period of time. To be notified of the disposition of an appeal or complaint and further appeal, as appropriate.
  • The right to appeal a decision to deny or limit coverage, first within the plan and then through an independent organization for a filing fee as applicable. The member also has the right to know that their doctor cannot be penalized for filing a complaint or appeal on the member’s behalf.
  • The right to choose a primary care provider within the limits of covered benefits and availability within the plan network. The member also has the right to refuse care from specific practitioners.
  • The right for AmeriHealth New Jersey members as defined by state law, to have a choice of specialists among participating network providers following an authorized referral, subject to their availability to accept new patients.
  • For members with chronic disabilities, the right to obtain assistance and referrals to providers who are experienced in treating their disabilities.
  • The right to candid discussions of appropriate or medically necessary treatment options for his or her condition, regardless of cost or benefit coverage, in terms that the member understands including an explanation of their medical condition, recommended treatment, risks of treatment, expected results, and reasonable medical alternatives. If the member is unable to easily understand this information, they have the right to have an explanation provided to their next of kin or guardian and documented in their medical record. The plans do not direct practitioners to restrict information regarding treatment options.
  • The right to have available and accessible services when medically necessary, including availability of care 24 hours a day, seven days a week for urgent and emergency conditions.
  • The right to call 911 in a potentially life-threatening situation without prior approval from the plan; the right to have the plan pay per contract for a medical screening evaluation in the emergency room to determine whether an emergency medical condition exists.
  • The right to continue receiving services from a provider who has been terminated from the plans’ network (without cause) in the timeframes as defined by the applicable state requirements. This continuation of care does not apply if the provider is terminated for reasons which would endanger the member, public health or safety, breach of contract, or fraud.
  • The rights afforded to members by law or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language you understand.
  • The right to be free from balance billing by providers for medically necessary services that are authorized or covered by AmeriHealth except as permitted for copayments, coinsurance, and deductibles, by contract.
  • The right to prompt notification of terminations or changes in benefits, services, or provider network.
  • The right to make recommendations regarding the plans’ Member Rights and Responsibilities Policy by contacting Customer Services in writing.

Commercial Member Responsibilities:

  • Members have the responsibility to communicate, to the extent possible, information the Plans, participating practitioners and providers need in order to care for the member.
  • Members have the responsibility to follow the plans and instructions for care that they have agreed on with their practitioners. This responsibility includes consideration of the possible consequences of failure to comply with recommended treatment.
  • Members have the responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
  • Members have the responsibility to review all benefit and membership materials carefully and to follow the rules pertaining to the health plan.
  • Members have the responsibility to ask questions to assure understanding of the explanations and instructions given.
  • Members have the responsibility to treat others with the same respect and courtesy expected for oneself.
  • Members have the responsibility to keep scheduled appointments or to give adequate notice of delay or cancellation.
  • The responsibility to pay deductibles, coinsurance or copayments, as appropriate, according to the member’s contract.
  • The responsibility to pay for charges incurred that are not covered under or authorized under the member’s benefit policy or contract.
  • The responsibility to pay for charges that exceed what the plan determines are customary and reasonable (usual and customary, or usual, customary and reasonable, as appropriate) for services that are covered under the out-of-network component of the member’s benefit contract with respect to point of service contracts.

Medicare Member Rights and Responsibilities Statement

Medicare Member Rights:

  • The right to be treated with fairness, respect, and recognition of the member’s dignity and right to privacy.
  • The member has the right to confidential treatment of personally identifiable health/medical information. The member also has the right to have access to his/her medical record in accordance with applicable Federal laws.
  • The right to see Plan providers and get covered services within a reasonable period of time.
  • The right to know treatment choices and participate with providers in decisions about the member’s health care. The health plans do not direct practitioners to restrict information regarding treatment options.
  • The right to choose providers, within the limits of covered benefits and availability within the health plans network and the right to refuse care from specific providers.
  • The right to a candid discussion of appropriate or medically necessary treatment options for the member’s medical conditions, regardless of cost or benefit coverage.
  • The right to have a choice of specialists among participating network providers following an authorization referral as applicable, subject to their availability to accept new patients.
  • The member has the right to receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, genetic information, color, religion, gender, national origin or source of payment.
  • The right to use advance directives (such as a living will or a power of attorney).
  • The member has a right to voice complaints or appeals about the health plan or care provided, and to receive a timely response. The member has a right to be notified of the disposition of appeals/complaints and the right to further appeal, as appropriate.
  • The right to get information about health care coverage and costs and to obtain information in other formats
  • The right to get information about the Plan, it services, its providers, and members’ rights and responsibilities.
  • The right to make recommendations regarding the Plan’s Member’s Rights and Responsibilities Policy.

Medicare Member Responsibilities:

  • The responsibility to give the Plan and providers the information they need to provide care (to the extent possible) and to follow agreed upon the treatment plans and instructions.
  • The responsibility to act in a way that supports the care provided to others and helps smooth the running of providers’ offices and facilities.
  • The responsibility to pay premiums and any cost shares the member may owe for covered services and meet your other financial responsibilities as described in the Evidence of Coverage.
  • The responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
  • The responsibility to advise the Plan of any questions, concerns, problems or suggestions.
  • The responsibility to notify providers that the member is enrolled in the health plan when seeking care (unless it is an emergency).
  • The responsibility to notify the health plan if the member has additional health insurance.
  • The responsibility to notify the health plan if the member moves out of the service area.