Member Rights and Responsibilities
Member Rights and Responsibilities
Through American Behavioral, you have the following rights and responsibilities:
Member Rights
American Behavioral believes that every Member has the right to:
- Be treated with dignity, respect and courtesy;
- Be treated without regard to race, religion, gender, sexual orientation, ethnicity, age, disability or communication needs;
- Confidentiality of protected health information and treatment information;
- Receive information about American Behavioral services, Providers, clinical guidelines, quality improvement programs, Member rights and responsibilities and any other rules or guidelines used in making coverage and payment decisions;
- A clear explanation of your health plan benefits and how to access services;
- Access to services and Providers that meet your needs;
- Choose or change your Provider;
- Request an interpreter or assistance for language translation or hearing problems;
- Participate in making your health care decisions by receiving appropriate information about your diagnosis, treatment options and prognosis;
- Participate in decisions concerning your care and treatment plan;
- An individualized treatment plan that is periodically reviewed and updated;
- Refuse or consent to treatment or tests to the extent provided by law and be made aware of the medical consequences of such decisions;
- Refuse to participate in any proposed investigational studies, clinical trials, or research projects;
- Receive treatment within the least restrictive environment;
- Give your health care Provider “advanced directives” (also called a “living will” or a “durable power of attorney for health care”) concerning options when you are unable to direct your own care. This may include your wishes concerning life support such as a respirator, tube feedings or the use of dialysis;
- Be informed of the reason for any adverse determination by utilization management, including the specific utilization review criteria or benefits provision used in the determination;
- Utilization Management decisions based on appropriateness of care. American Behavioral does not reward Providers or other individuals conducting Utilization Review for issuing adverse determinations;
- Submit either positive or negative comments concerning your care to American Behavioral, your health care Provider(s) or your employer;
- Information about how to file a formal complaint or appeal;
- Voice complaints regarding use or disclosure of protected health information;
- Receive a copy of these rights and responsibilities;
- Make recommendations regarding these rights and responsibilities; and
- To appoint your next of kin, a legal guardian or legal designee to exercise these rights if you are unable to do so.
Member Responsibilities
American Behavioral believes that every Member has the responsibility to:
- Know your health plan benefits and adhere to the guidelines of your policy;
- Provide an accurate medical and social history. This includes granting a release of medical records from former Providers, if needed;
- Respect the rights, privacy, and confidentiality of other Patients and their families;
- Gather and carefully consider all information needed to give consent for treatment or to refuse care;
- Cooperate with the agreed upon treatment plan, instructions and guidelines, and to discuss the results with your Provider;
- Notify your health care Provider when you expect to be late for an appointment or need to cancel;
- Ask questions regarding your illness or treatment and to tell your Provider about your expectations of treatment;
- Provide a copy of your “advanced directives” to your Provider whenever changes are made; and
- Ensure timely payment for your treatment.
