As a patient, you have rights and responsibilities.
Respect and Non-Discrimination: You have the right to be treated with respect by CareCentrix team members. You have the right to be treated fairly and equally as required by law.
Accurate, Understandable Information: You have the right to receive correct information in a form you can understand. This includes information about the utilization review process, its rules, and our nurse coaching program.
Confidentiality of Health Information: You have the right to speak with CareCentrix team members and feel safe that your health information will remain private as required by law.
Qualified Health Care Professionals: You have a right to have your utilization review requests handled by qualified health care professionals. You have the right to have a doctor issue any denial decision. You also have a right to have clinical questions that arise during our nurse coaching program handled by qualified health care professionals.
Clinical Rationale for Denials, Peer-to-Peer Conversations, and Appeals: You have the right to a fair and efficient utilization review process. You may request a copy of the clinical rationale used in reaching a denial decision. You or your doctor may request a peer-to-peer review to discuss the clinical details of a case before or after a decision is made. You may appeal a denial decision. The appeal process is set out in your health plan evidence of coverage and denial letter.
Complaints: You have the right to make a complaint and get a response. Complaints can be filed with any CareCentrix team member. Your complaint will be handled according to the CareCentrix complaint process. The complaint process is available to you upon request.
You have a responsibility to take part in the utilization management process and, as applicable, our nurse coaching program. This includes:
- Telling us important information and clearly sharing your wants and needs.
- Knowing about your health plan coverage including plan limitations, benefits, and exclusions.
- Following the procedures of your health plan.
- Using the complaint or appeal processes to address your concerns.
- Reporting wrongdoing and fraud to the correct party.