Members Rights & Responsibilities

As a Physicians Health Choice Member, You Have the Right to the following:

Timely, Quality Care:

Choose a Physicians Health Choice Primary Care Physician (PCP). We will let you know which doctors are accepting new patients.
To go to a Physicians Health Choice women's health specialist (such as a gynecologist) without a referral for a yearly well woman exam.
A discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
Timely access (means that you can get appointments and services within a reasonable amount of time) to your PCP and referrals to specialists when medically necessary.
Timely access to all Covered Services, both clinical and non-clinical.
Access Emergency Services without Prior Authorization when you, as a prudent layperson, acted reasonably, believing that an Emergency Medical Condition existed. If you believe you have an emergency – you will be covered.
Receive Urgently Needed Care when traveling outside the Plan’s Service Area or in the Plan’s Service Area when unusual or extenuating circumstances prevent you from obtaining care from your Physicians Health Choice Plan Provider.

Treatment with Fairness and Respect:

Be treated with dignity, respect and fairness at all times.
Physicians Health Choice must obey laws against discrimination that protect you from unfair treatment. These laws say that we cannot discriminate against you (treat you unfairly) because of your race or color, age, religion, national origin, any mental or physical disability, gender, sexual orientation, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for your care. Expect these rights to be upheld by both Physicians Health Choice and our Plan Providers.

Privacy of Your Medical Records and Personal Health Information:

Receive protection according to state and federal laws to protect the privacy of your medical records and personal information.
Confidential treatment of all communications and records pertaining to your care.
Access and obtain copies of your medical records (there may be a fee charged for making copies).
Timely access to your records and any information that pertains to them.
Request Physicians Health Choice or its Plan Providers to make additions and corrections to your medical records which will be reviewed and determination made as to whether or not appropriate.
Know how your health information has been distributed and used for non-routine purposes.
Generally, Physicians Health Choice must get written permission from you (or from someone you have given legal power to make decisions for you) before medical records can be made available to any person not directly concerned with your care or responsible for making payments for the cost of such care. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care.
Physicians Health Choice will make sure that unauthorized individuals will not see or change your medical records.
Physicians Health Choice is required to provide you with a notice that tells about your privacy rights and explains how we protect the privacy of your health information.

Treatment Choices and Your Participation:

Actively participate in decisions about your own health and treatment options. Physicians Health Choice Plan Providers must explain things in a way that you can understand.
Know about all of the treatment choices that are recommended for your condition, no matter what they cost and whether or not they are covered by Physicians Health Choice.
Be told about any risks involved in your care.
Be told in advance if any proposed medical care or treatment is part of a research experiment, and be given the choice of refusing experimental treatments.
Receive a detailed explanation from us if you believe a Physicians Health Choice Plan Provider has denied care that you believe you are entitled to receive or care you believe you should continue to receive.
Refuse treatment or leave a medical facility, even against the advice of physicians (providing you accept the responsibility and consequences of your decision).
Information about your medications – what they are, how to take them and possible side effects.
Be informed of continuing health care requirements following discharge from inpatient or outpatient facilities.

Advance Directives Such as a Living Will or Durable Power of Attorney for Health Care:

Complete and distribute an Advance Directive, Living Will or other directive to your Physicians Health Choice Plan Providers.
Extend your rights to any person who may have legal responsibility to make decisions on your behalf regarding your medical care.
Be involved in decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment.

Solving Problems in a Timely Manner:

Make a complaint if you have concerns or problems related to your coverage or care.
Responsiveness to reasonable requests made for covered services.
Make complaints regarding grievances and appeals without being discriminated and expect problems to be fairly examined and appropriately addressed.
Get a summary of information about the appeals and grievances that members have filed against Physicians Health Choice in the past.

Information About Your Health Care Coverage and Costs:

Evidence of Coverage which includes covered services and what you have to pay.
Explanation from us about any bills you may get for services not covered by Physicians Health Choice and in writing why we will not pay for or allow you to get services as well as how you can file an appeal to change this decision.

Information About Physicians Health Choice and Our Plan Providers:

Know names and qualifications of physicians and health care professionals involved in your medical treatment.
Physicians Health Choice financial condition.

As a Physicians Health Choice Member, Your Responsibilities Include:

To get familiar with your Physicians Health Choice coverage and the rules you must follow to get care as a member. You can use the information we give you to learn about your coverage, what you have to pay and the rules you need to follow. Please call Customer Service.
To give your doctor or other health care providers the information they need to care for you.
To follow the treatment plans and instructions that you and your doctors agree upon. Be sure to ask your doctor and other providers if you have questions.
Do your part to improve your own health condition by following treatment plans, instructions and care that you have agreed on with your physician(s).
To act in a way that supports the care provided to other patients and helps the smooth running of your doctor’s office, hospitals and other health care facilities.
To pay your plan premiums (if applicable) and any co-payments or coinsurance you may owe for the covered services you get.
To let us know if you have any questions, concerns, problems or suggestions. If you do, please call the Physicians Health Choice Customer Service Department at 1-866-550-4736.

Appeals and Grievances

Physicians Health Choice encourages you to let us know if you have questions, concerns, or problems related to your covered services or the care you receive. This section will explain more about the rules for filing complaints in different types of situations.

View Appeals and Grievances