MEMBER RIGHTS
As a Member, you have the right to know details about PMHM and how we do business, including:
- The name and title of the staff member who is assisting you
- What your benefit plan covers
- How we make our decisions about insurance coverage for treatment
- Your Member rights and responsibilities
You have the right to know about PMHM’s Network Providers including:
- Their specialties
- Licensures
- Address, phone and office hours of clinic or facility
- Demographic information such as gender, race, language spoken, etc. (if available)
- You have the right to have your treatment information and diagnosis remain confidential, except as required by State or Federal law. Regarding the release of your treatment information to others, including your family members, PMHM will not release information without a signed form from you or your legal guardian permitting us to do so.
- In your interactions with PMHM’ staff, you have the right to be treated with privacy, courtesy and respect.
- You have the right to participate in the decisions which are made about your treatment.
- You have the right to discuss your best treatment options with your Provider regardless of the cost or your insurance coverage.
- You have the right to discuss what you feel your rights and responsibilities should be with PMHM.
- You have the right to make informal or formal complaints about PMHM’s staff, services or the care given by Providers.
- You have the right to undertake a formal appeal if you disagree with a decision made by PMHM about your treatment coverage.
- You have the right to designate another person to speak to PMHM on your behalf.
- You have the right to understand your insurance coverage and how to seek treatment.
- You have the right to receive timely care consistent with your individual needs.
- You have the right to know all the information about any treatment charges you receive, even if the insurance company is making payment.
MEMBER RESPONSIBILITIES
As a Member, you have the following responsibilities with regard to your treatment:
- You have the responsibility to provide PMHM with all previous treatment records that it may need to arrange your care.
- You have the responsibility to actively work with your Provider to develop your treatment plan and to learn about your condition.
- You have the responsibility to follow the treatment plan agreed upon by you and your Provider.
- You have the responsibility to help PMHM obtain information about any out of network treatment you are receiving or have received.
- You have the responsibility to notify PMHM and your Provider if your demographic information changes (id name, address, phone number, etc.)
Appeals
PMHM’s Professionally Guided Care Program SM seeks to ensure that each patient receives the correct treatment in the most appropriate treatment setting. After the expiration of PMHM’s initial authorization, the Provider may request more treatment sessions or days as required. Regardless of PMHM’s authorization with regard to benefit payment, the Provider or Facility must provide all of the treatment each patient requires.
In the event that PMHM denies further benefit payments, the Member may initiate an appeal. PMHM’s Case Management Program consists of a three-tiered approach, incorporating peer review initially and independent reviewers at the highest levels of appeal. PMHM’s standards for Clinical Appeals conduct are one (1) business day for expedited appeals, and ten (10) business days for standard appeals with a chart review. For more information about PMHM’s Appeals Process or to initiate an appeal, please call 800-776-4357.
