Rights and Responsibilities

Our members have rights and responsibilities when participating in an MCO. Member Services representatives serve as advocates for Wellpoint members.

Members have the right to:

Be treated respectfully and with due consideration for dignity and privacy
Privacy during a visit with their doctor
Talk about their medical record with their PCP, ask for a summary of that record and request to amend or correct the record as appropriate
Be properly educated about and helped to understand their illness and available health care options, including a candid discussion of appropriate clinically or medically necessary treatment options, including medication treatment options regardless of the cost or benefit coverage
Participate in decision‑making about the health care services they receive
Refuse health care (to the extent of the law) and understand the consequences of their refusal
Be free from any form of restraint, seclusion as a means of coercion, discipline, inconvenience or retaliation as specified in other federal regulations on the use of restraints and seclusion
Decide ahead of time regarding the kinds of care they want if they become sick, injured or seriously ill by making a living will
Expect their records (including medical and personal information) and communications will be treated confidentially
If under age 18 and married, pregnant or have a child, be able to make decisions about his or her own health care and/or his or her child’s health care
Choose their PCP from the Wellpoint network of providers
Make a complaint to Wellpoint and get a response within 30 days
Have information about Wellpoint, its services, practitioners, and provider and member rights and responsibilities
Receive information on the Notice of Privacy Practices as required by the Health Insurance Portability and Accountability Act (HIPAA)
Get a current member handbook and a directory of health care providers within the Wellpoint network
Choose any Wellpoint network specialist
Change their doctor to another Wellpoint network doctor if the doctor is unable to refer them to the Wellpoint network specialist of their choice
Be connected to health care providers for ongoing treatment of chronic disabilities
Have access to their PCP or a backup 24 hours a day, 365 days a year for urgent or emergency care
Receive care right away from any hospital when their medical condition meets the definition of an emergency
Receive post-stabilization services following an emergency condition in some situations
Call the Wellpoint toll-free, 24-hour Nurse HelpLine. English: 1-866-864-2544; Spanish: 1-866-864-2545
Call the Wellpoint toll-free Member Services telephone line from 8 a.m. to 6 p.m. Eastern time, Monday to Friday
Know what payment methodology Wellpoint utilizes with health care providers
Receive assistance in filing a grievance and/or appeal and appeal through the Wellpoint internal system
File a grievance or appeal if he or she is not happy with the results of a grievance and receive acknowledgement within 10 days and a resolution within 30 days
Ask Wellpoint to reconsider previously denied coverage; upon receipt of the member’s medical information, Wellpoint will review the request
Freely exercise the right to file a grievance or appeal such that exercising of these rights will not adversely affect the way the member is treated
Receive notification to present supporting documentation for their appeal
Examine files before, during and after their appeal
Request an administrative hearing when dissatisfied with the Wellpoint decision
Continue to receive benefits pending the outcome of an appeal decision or state administrative hearing if the appropriate rules are followed
Only be responsible for cost-sharing in accordance with 42 CFR 447.50-42 CFR 447.60 and Maryland provisions for Medicaid
To make recommendations regarding the Wellpoint Rights and Responsibilities Policy

Members have the responsibility to:

Treat their providers, their providers’ staff and Wellpoint employees with respect and dignity
Not behave in a disruptive manner while in the provider’s office
Respect the rights and property of all providers
Cooperate with people providing health care
Tell their PCP about their symptoms and problems and ask questions
Get information and consider treatments before they are performed
Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible
Discuss anticipated problems with following their provider’s directions
Consider the outcome of refusing treatment recommended by a provider
Follow plans and instructions for care they have agreed on with their providers, to the best of their ability
Help their provider obtain medical records from the previous provider and help their provider complete new medical records as necessary
Supply information (to the extent possible) the organization and its practitioners and providers need to provide care
Respect the privacy of other people waiting in providers’ offices
Call Wellpoint and change their PCP before seeing a new PCP
Make and keep appointments and arrive on time; members should always call if they need to cancel an appointment, change an appointment time or if they will be late
Discuss complaints, concerns and opinions in an appropriate and courteous way
Tell their provider how they want to receive their health information
Obtain medical services from their PCP
Learn and follow the Wellpoint policies outlined in the member handbook
Read the member handbook to understand how Wellpoint works
Notify Wellpoint when a member or family member who is enrolled in Wellpoint has died
Become involved in their health care and cooperate with their provider about recommended treatment
Learn the correct method by which his or her medications should be taken
Carry his or her Wellpoint ID card at all times and quickly report any lost or stolen cards to Wellpoint; members should contact Wellpoint if information on the ID card is wrong or if there are changes to their name, address or marital status.
Show their ID cards to each provider
Tell Wellpoint about any providers they are currently seeing
Provide true and complete information about their circumstances
Report change(s) in their circumstances
Notify his or her PCP as soon as possible after they receive emergency services
Go to the emergency room only when they have an emergency
Report suspected fraud and abuse