Other Important Information

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Emergency Benefits - See How to Obtain Care After Normal Office Hours/Emergency Care

It can be hard to know what to do when you or one of your family members has an accident or needs immediate care. Coventry Health Care provides benefits for medical emergencies. Learn More

Complaints and Appeals

Complaint and appeal policies are in place to ensure that we have effective procedures for addressing, documenting, and resolving complaints or appeals.

The complaint procedure gives a member the right to express dissatisfaction with any aspect of the organization and to request review of any matter related to:

• The quality of health care service received
• General inquiries about covered service
• Member rights and responsibilities

The appeals procedures give members the opportunity to ask us to review any matter related to:
• Issues about the scope of coverage for health care services
• Medical necessity of services requested
• Denial of care/services/claim
• Other adverse benefit determinations

Notice of Appeal Rights

It is the policy of CHC-LA as well as the Department of Labor and the State of Louisiana that all members shall have the right to appeal any adverse decision made by the Plan. You may represent yourself in your appeal or you may designate a representative. Your provider may appeal on your behalf, likewise a hospital who is responsible for your care may also file an appeal. You may call the Member Services Department at 800-341-6613 for further assistance regarding the appeal process. You have the right to appeal in writing or by telephone.  Complaint and appeal information is located in your Certificate of Coverage (COC), section Resolving Complaints and Grievances. The COC can be viewed in our website under the member section My Group Benefits; if you need a copy please call our Customer Service department using the number on the back of your member ID card.

External Review

If your appeal involves a medical judgment (including, but not limited to, those based on the Plan’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit), you may be entitled to file a request for external review. If your appeal involves our denial to provide or pay for health care service or treatment deemed to be experimental or investigational, you may be entitled to file a request for external review. We will issue a final internal adverse benefit determination upon completion of a first and second level medical necessity appeal. Under the external review process, our adverse benefit determination will be reviewed by independent health care professionals who have no association with us and who have appropriate training and experience in the field of medicine involved in the medical judgment. You must send a written request for external review within four (4) months after receipt of your final adverse benefit determination. You will be notified of the decision within 45 calendar days.

If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an expedited external review. You have the right to file for an expedited external review concurrently with your filing of a request for an internal review of an urgent care appeal and ongoing treatment. Under the expedited external review process, a final determination will be issued within 72 hours from the time of receipt of the request.

Financial Compensation - Doctors Make the Decisions

Utilization Management (UM) is a system for reviewing eligibility for benefits for the care that has been or will be provided to members. The UM department is composed of Preauthorization, Concurrent review, and Case management.

Our policy for payment of services rendered is to make sure that decisions are made because they are what our policies say we will do. There are no financial incentives in the review process.

• Utilization Management decision-making is supported by clinical decision tools and criteria and its intent is to determine whether the care and/or service are medically necessary and delivered at the appropriate level of care. Decisions also take into account the member’s benefit plan and coverage.
• The payment that CHC provides does not encourage decisions that result in denial of care that result in under utilization

How We Evaluate New Technology

Doctors and health care manufacturers are constantly developing new technologies. They can include anything from a new way to perform a procedure to a new use for a piece of equipment. So Coventry Health Care, Inc. established a system to review and evaluate new technologies.

When a new technology is presented to Coventry, we do a thorough review of existing literature. The opinion of experts in the field may be requested. They may also contact the accrediting body of the appropriate medical specialty.

Coventry compares the information against established criteria. Then we decide whether to provide coverage. All of our decisions are based on making sure you have the appropriate care and services. We continue to focus on providing our members with quality health care products.

Member Rights and Responsibilities

Did you know that as a member of Coventry you have certain rights and responsibilities? Knowing your rights and responsibilities will help you, your family, your provider, and Coventry ensure that you get the covered services and care that you need.

You have the right to:

• receive information about the organization, its services, its practitioners and providers and member rights and responsibilities
• to be treated with respect and recognition of your dignity and your right to privacy
• to participate with practitioners in making decisions about your health care
• a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage
• voice complaints or appeals about the organization or the care it provides
• make recommendations regarding the organization's member rights and responsibilities policy

You have the responsibility to:
• supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care
• follow plans and instructions for care that you have agreed to with your practitioners
• understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible

Your Privacy Matters

Coventry Health Care, Inc. and its affiliated companies appreciate the opportunity to provide health care benefits to you and your family. In the course of providing the health benefit plans we administer or offer, Coventry must collect, use, and disclose nonpublic personal information. We need information about you to manage your benefits. We collect your information from many sources and keeping your information safe is one of our most important jobs. We make sure that only people who need to use your information, whether that would
be orally, written or electronically, have access to it. On a routine basis, we may use and share your PHI to:

• provide for your treatment or authorization
• pay for your healthcare
• review the quality of the care you get
• tell you about your choices for care
• manage our health plan
• access, use or share PHI for other purposes as required or permitted by law

These uses are covered under state and federal laws. We consider this information private and confidential, and consequently we have policies and procedures in place to protect the information against unlawful use and disclosure. Notice of Privacy Policies can be viewed on our website through the Member Document Library page. Paper copies of the privacy notices are available by calling Customer Service using the number located on your member ID card.

Quality Improvement Program

Our Quality Improvement (QI) program works to ensure that all of our services meet high standards of quality and safety. Each year Coventry Health Care of Louisiana strives to improve all services provided. This is done by setting goals and works towards meeting these goals. These goals are included in a Quality Improvement (QI) program. Our goal is to help you take better care of yourself and your family. As part of the QI program, Coventry helps you take care of your health and get the best service possible.The QI program includes, but is not limited to improve:

  • Member satisfaction
  • Safety of care
  • Services
  • Access and availability to network providers
We look for problems and seek opportunities to make improvements. The goals and objectives of the QI program are to:
  • Make sure that reliable methods are used to measure results of our services.
  • Involve staff to support the quality improvement process.
  • Focus always on quality issues of high importance.
  • Remain sensitive to the cultural and language needs of those we serve to enhance healthcare delivery.
  • Ensure that all state and national regulatory requirements are met.
  • Maintain accreditation for the health plan. Accreditation is earned from the National Committee for Quality Assurance (NCQA).

All doctors and staff involved in the QI program respect the private nature of information they see. The QI program is evaluated each year to ensure that it is useful and meets NCQA standards.

Annual Quality Improvement Program Evaluation

The Quality Improvement program is evaluated on an annual basis to ensure the program structure is effective and meaningful and meets regulatory standards and guidelines. The results are used to develop and prioritize the annual quality work plan for the upcoming year and assure the effectiveness of the program. If you have any questions about our QI program, please call Customer Service using the number on the back of your Member ID card.

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