Patient Rights and Responsibilities

As a patient, you have rights and responsibilities.

Rights:

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.

Responsibilities:

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.