ValueOptions

 

COMPANY

INFORMATION

 

 

 

 

PROVIDER

INFORMATION

 

 

 

 

 

CONFIDENTIALITY

 

 

RESPECT

 

MEMBER INPUT

 

 

 

 

COMPLAINTS & APPEALS

 

 

 

 

 

ACCESS TO CARE, SERVICE & BENEFITS

 

 

 

CLAIMS & BILLINGS

 

 

 

 

 

 

 


Signature             Date

 

 

 

MEMBER RIGHTS

 

 

 

You have the right to know about ValueOptions and how we do business, including:

  • Names and titles of staff members

  • Services covered by your benefit plan

  • How we make decisions about approving payment for treatment

  • Your rights and responsibilities as a member

You have the right to know about ValueOptions participating providers including:

  • Clinical Licenses

  • Specialties

  • Addresses, phone numbers, office hours

  • Demographic information such as race or gender (if available)

You have the right to have information about your diagnosis and treatment kept confidential. However, sometimes the law requires ValueOptions to release such information. ValueOptions will only release information to others about your diagnosis and treatment if you, or your legal guardian, sign a form allowing such a release.

 

In your interactions with ValueOptions staff, you have the right to be treated with respect, dignity and privacy.
 

You have the right to be a part of decisions that are made about plans for your care.

 

You have the right to talk with your provider about the best treatment options for your condition, regardless of the cost of such care, or benefit coverage.

 

You have the right to tell ValueOptions what you thing your rights and responsibilities as a member should be.

 

You have the right to make complaints about ValueOptions staff, services or the care given by providers.

 

You have the right to appeal if you disagree with a decision made by ValueOptions about your care. ValueOptions administers your appeal rights as stipulated under your benefit plan.
 

 

You have the right to have anyone you choose speak for you in your contacts with ValueOptions.

 

You have the right to know about covered services and benefits offered under your plan, and how to seek these services.
 

You have the right to receive timely care consistent with your need for care.
 

You have the right to know the facts about any charge or bill you receive, no matter who is making payment.

 

MEMBER RESPONSIBILITIES

 

You have the responsibility to provide information (including past treatment records) that ValueOptions or your provider may need to plan your treatment.
 

You have the responsibility to learn about your condition and work with your provider to develop a plan for your care.

 

You have the responsibility to follow the plans and instructions for care you have agreed to with your provider.

 

You have the responsibility to help ValueOptions obtain such items as approvals for out of network payment for treatment an referrals.
 

You have the responsibility to notify ValueOptions and your provider of changes. This includes an address or phone number change.