In your interactions with CareCentrix, you have rights and responsibilities, which include:
Respect and Nondiscrimination: You have the right to considerate, respectful service from CareCentrix team members and to be treated fairly, without unlawful discrimination.
Accurate, Understandable Information: You have the right to receive accurate, easily understandable information, including information about the utilization review process and its requirements and our nurse coaching program.
Confidentiality of Health Information: You have the right to communicate with CareCentrix team members in confidence, and to have your individually identifiable health information remain confidential and protected.
Qualified Health Care Professionals: You have a right to have your utilization review requests handled by qualified health care professionals and to have a physician 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 treating physician, may request a peer-to-peer conversation to discuss the clinical details of a case before a decision is made, or after a denial decision is made. You may request an appeal when a denial decision is made in accordance with the appeal process specified in your health plan evidence of coverage and denial letter.
Complaints: You have the right to report complaints and expect a response. Complaints can be registered with any CareCentrix team member and will be handled according to the CareCentrix complaint process, which is available upon request.
You have a responsibility to participate in the utilization management process and, as applicable, our nurse coaching program, including:
Disclosing relevant information and clearly communicating your wants and needs
Being knowledgeable about your health plan coverage including plan limitations, benefits, and exclusions.
Abiding by the administrative procedures of your health plan.
Using complaint and appeal processes to address concerns you may have.
Reporting wrongdoing and fraud to the appropriate party.