CountyCare - Provider Rights and Responsibilities

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Provider Rights and Responsibilities

CountyCare focuses on improving member health status, as well as member and provider satisfaction in a coordinated care environment. To achieve our goals, we have established rights and responsibilities for both members and providers. Providers and members are able to apply their rights without any action taken against them. Should you believe your rights, or the rights of a CountyCare member have been violated, please call Provider Services at 312-864-8200 / 855-444-1661 / 711 TTD/TTY.

You can find the Provider Rights and Responsibilities in the Provider Manual or by .

  1. Be treated by their patients and other healthcare workers with dignity and respect
  2. Receive accurate and complete information and medical histories for members’ care
  3. Have their patients act in a way that supports the care given to other patients and that helps keep the doctor’s office, hospital, or other offices running smoothly
  4. Expect other network providers to act as partners in members’ treatment plans
  5. Expect members to follow their directions, such as taking the right amount of medication at the right times
  6. Help members or advocate for members to make decisions within their scope of practice about their relevant and/or medically necessary care and treatment, including the right to:
    1. Recommend new or experimental treatments
    2. Provide information regarding the nature of treatment options
    3. Provide information about the availability of alternative treatment options, therapies, consultations, and/or tests, including those that may be self-administered
    4. Be informed of the risks and consequences associated with each treatment option or choosing to forego treatment
  7. Make a complaint or file an appeal against CountyCare and/or a member
  8. File a grievance with CountyCare on behalf of a member, with the member’s consent
  9. Have access to information about CountyCare’s quality improvement programs, including program goals, processes, and outcomes that relate to member care and services.  This includes information on safety issues
  10. Contact CountyCare’s Provider Services with any questions, comments, or problems, including suggestions for changes in the QIP’s goals, processes, and outcomes related to member care and services
  11. Treat members with fairness, dignity, and respect
  12. Not discriminate against members on the basis of race, color, national origin, disability, age, religion, mental or physical disability, or limited English proficiency
  13. Maintain the confidentiality of members’ personal health information, including medical records and histories, and adhere to state and federal laws and regulations regarding confidentiality
  14. Give members a notice that clearly explains their privacy rights and responsibilities as it relates to the provider’s practice/office/facility
  15. Provide members with an accounting of the use and disclosure of their personal health information in accordance with HIPAA
  16. Allow members to request restriction on the use and disclosure of their personal health information
  17. Provide members, upon request, access to inspect and receive a copy of their personal health information, including medical records
  18. Provide clear and complete information to members, in a language they can understand, about their health condition and treatment, regardless of cost or benefit coverage, and allow the member to participate in the decision-making process
  19. Tell a member if the proposed medical care or treatment is part of a research experiment and give the member the right to refuse experimental treatment
  20. Allow a member who refuses or requests to stop treatment the right to do so, as long as the member understands that by refusing or stopping treatment the condition may worsen or be fatal
  21. Respect members’ advance directives and include these documents in the members’ medical record
  22. Allow members to appoint a parent, guardian, family member, or other representative if they can’t fully participate in their treatment decisions
  23. Allow members to obtain a second opinion, and answer members’ questions about how to access healthcare services appropriately
  24. Collaborate with other healthcare professionals who are involved in the care of members
  25. Obtain and report to CountyCare information regarding other insurance coverage
  26. Follow all state and federal laws and regulations related to patient care and patient rights
  27. Participate in CountyCare data collection initiatives, such as HEDIS and other contractual or regulatory programs
  28. Review clinical practice guidelines distributed by CountyCare
  29. Comply with CountyCare’s Medical Management program as outlined in this manual.
  30. Notify CountyCare in writing if the provider is leaving or closing a practice
  31. Contact CountyCare to verify member eligibility or coverage for services, if appropriate
  32. Disclose overpayment or improper payments to CountyCare
  33. Invite member participation, to the extent possible, in understanding any medical or behavioral health problems that the member may have and to develop mutually agreed upon treatment goals, to the extent possible
  34. Provide members, upon request, with information regarding office location, hours of operation, accessibility, and languages, including the ability to communicate with sign language
  35. Provide members, upon request, with information regarding the provider’s professional qualifications, such as specialty, education, residency, and board certification status
  36. Only provide members with HFS approved health plan marketing materials, including flyers and letters
  37. Not be excluded, penalized, or terminated from participating with CountyCare for having developed or accumulated a substantial number of patients in the CountyCare with high-cost medical conditions
  38. Object to providing relevant or medically necessary services on the basis of the provider’s moral or religious beliefs or other similar grounds
  39. Disclose to CountyCare, on an annual basis, any physician incentive plan (PIP) or risk arrangements the provider or provider group may have with physicians either within its group practice or other physicians not associated with the group practice even if there is no substantial financial risk between CountyCare and the physician or physician group