Rights and responsibilities

Member rights

Wellpoint members have the right to:

Privacy:

• Be treated with respect and with due consideration for their dignity and privacy
• Expect that we will treat their records, including medical and personal information and communications, confidentially
• Request and receive a copy of their medical records at no cost to the member and the request that the records be amended or corrected
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation as specified in federal regulations

Take part in decisions regarding their healthcare:

• Receive information on available treatment options and alternatives presented in a manner appropriate to the member’s condition and ability to understand
• Engage in candid discussions of appropriate or medically necessary treatment options for their conditions regardless of cost or benefit coverage
• Receive the appropriate services that are not denied or reduced solely because of medical condition
• Refuse healthcare (to the extent of the law) and understand the consequences
• Decide ahead of time the care they want if they become sick, injured, or seriously ill by making a living will
• Be able to make decisions about their children’s healthcare if members are younger than age 18 and married, pregnant, or have children
  

Grievances, appeals, and fair hearings:

• Pursue resolution of grievances and appeals about the health plan or care provided
• Freely exercise filing a grievance or an appeal without adversely affecting the way they are treated
• Continue to receive benefits pending the outcome of an appeal or a fair hearing under certain circumstances, where allowed by law

Wellpoint information:

• Receive the necessary information to be a Wellpoint member in a manner and format they can understand easily
• Receive a current member handbook and provider directory
• Receive a copy of the member handbook and/or provider directory by request by calling Member Services at 800-782-0095
• Receive assistance from Wellpoint in understanding the requirements and benefits of the plan
• Receive notice of any significant changes in the benefit package at least 30 days before the intended effective date of the change
• Make recommendations about our rights and responsibilities policies
• Know how we pay our providers

Medical care:

• Choose their PCPs from our network of providers
• Choose any Wellpoint network specialist after getting a referral from their PCPs, if appropriate
• Be referred to healthcare providers for ongoing treatment of chronic disabilities
• Have access to their PCPs or backups 24 hours a day, 365 days a year for urgent or emergency care
• Get care right away from any hospital when their symptoms meet the definition of an emergency medical condition
• Get post-stabilization services following an emergency medical condition in certain circumstances
• Be free from discrimination and receive covered services without regards to race, color, creed, gender, religion, age, national origin ancestry, marital status, sexual preference, health status, income status, program membership, or physical or behavioral disability, except where medically indicated

Member responsibilities

Members have the responsibility to:

Respect their healthcare providers:

• Treat their doctors, their doctors’ staff, and employees of Wellpoint with respect and dignity
• Not be disruptive in the doctor’s office
• Make and keep appointments and be on time
• Call if they need to cancel an appointment, change the appointment time, or call if they will be late
• Respect the rights and property of all providers

Cooperate with the people providing healthcare:

• Tell their providers about their symptoms and problems, and ask questions
• Supply information providers need in order to provide care
• Understand the specific health problems and participate in developing mutually agreed-upon treatment goals as much as they are able
• Discuss problems they may have with following their providers’ directions
• Follow plans and instructions for the care they have agreed to with their practitioner
• Consider the outcome of refusing treatment recommended by a provider
• Discuss grievances, concerns, and opinions in an appropriate and courteous way
• Help their providers obtain medical records from their previous providers and help their providers complete new medical records as necessary
• Secure referrals from their PCPs when specifically required before going to another health care provider unless they have a medical emergency
• Know the correct way to take medications
• Go to the emergency room when they have an emergency
• Notify their PCPs as soon as possible after they receive emergency services
• Tell their doctor who they want to receive their health information Follow 

Wellpoint policies outlined in the member handbook:

• Provide proper identification during enrollment
• Carry their Wellpoint ID cards with them at all times, and report any lost or stolen cards
• Contact the Wellpoint Member Services team if information on their ID cards is wrong or if there are changes to their name, address, or marital status
• Call us and change their PCP before seeing the new PCP
• Tell us about any doctors they are currently seeing
• Notify Wellpoint if a member or family member who is enrolled in Wellpoint has died
• Report suspected fraud and abuse

Primary care provider (PCP) roles and responsibilities

Who are considered PCPs?

A PCP is a specific clinician responsible for coordinating the health care needs of certain members. Providers with the following specialties can be designated as PCPs:

• General practice
• Family practice Internal medicine
• Pediatrics
• OB/GYN
• Physician assistants
• Certified nurse midwives
• Advanced practice nurses (nurse practitioners)

When members enroll in any of our programs, they choose a PCP or are assigned one. PCPs agree to accept member assignment and are the principle point of contact for our members in coordinating and managing their care.

The role of the PCP

The PCP’s role is to provide members with a medical home — the member’s first stop in the healthcare process and a centralized hub for a wide variety of ongoing healthcare needs. Wellpoint furnishes each PCP with a current list of enrolled members assigned to that PCP. 

The PCP’s role is to:

• Coordinate members’ healthcare 24 hours a day, 7 days a week
• Develop members’ care and treatment plans, including preventive care
• Maintain members’ current medical records, including documentation of all services provided by the PCP and any specialty or referral services
• Adhere to wait times, as outlined within the provider contract and the provider manual
• Referrals for specialty care and other medically necessary covered services, both in-network and out-of-network, consistent with Wellpoint’s utilization management (UM) policies
• Coordinate with outpatient clinical services
• Provide complete information about proposed treatments and prognosis for recovery to our members or their representatives
• Facilitate interpreter services by presenting information in a language that our members or their representatives can understand
• Ensure that members’ medical and personal information is kept confidential, as required by state and federal laws
• Obtain signed consent before providing care
• Adhere to Wellpoint and West Virginia Medicaid managed care program policies
• Facilitate adherence to the EPSDT periodicity schedule

Responsibilities of the PCP

The PCP’s scope of responsibilities includes providing or arranging for:

• Routine and preventive healthcare services
• Emergency care services
• Behavioral health services
• Hospital services
• Ancillary services
• Interpreter services
• Referrals for specialty services
• Coordination with outpatient clinical services, such as therapeutic, rehabilitative, or palliative services

Learn more

To learn more about our utilization management program or our care management model, please refer to your provider manual or contact Provider Services.

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