Your Rights
Enrollment with PHP entitles you to:
1. Be given information about your rights and responsibilities as a member.
2. Be treated at all times with respect and recognition of your dignity and right to privacy.
3. Choice of and ability to change a primary care physician (PCP) from a list of network physicians or practitioners.
4. Information on the nature and consequence of appropriate or medically necessary treatment options that may be involved in your health care, regardless of cost or benefit coverage in terms you can reasonably be expected to understand and so that you can give informed consent prior to initiation of any procedure and/or treatment.
5. The opportunity to participate in decisions involving your health care, including, making decisions to accept or refuse medical or surgical treatment and to be given information on the consequences of refusing or not complying with treatment.
6. Voice complaints or appeals about PHP or the care provided and/or use PHP’s complaint/appeal procedure to resolve problems without fear of being penalized or retaliated against and/or without fear of loss of coverage.
7. Be given information about PHP, its services, and the physicians and practitioners who provide health services, including the qualifications of network providers.
8. Make suggestions regarding PHP’s member rights and responsibilities policies.
Your Responsibilities
As a covered person, you are expected to:
1. Select or be assigned a Primary Care Physician from PHP’s list of network providers and notify PHP when you have made a change.
2. Be aware that all hospitalizations must be authorized in advance by PHP and arranged by your PCP or network specialist, except in emergencies or for urgently needed health services.
3. Use emergency room services only for treatment of a serious medical condition resulting from injury, sickness or mental illness, which arises suddenly and requires immediate care and treatment (generally within 24 hours of onset) to avoid jeopardy to your life or health.
4. Always carry your PHP ID card, present it to the provider each time you receive health services, never permit its use by another person, report its loss or theft to us and destroy any old cards.
5. Notify the health plan of any changes in address, eligible family members and marital status, or if you acquire other health insurance coverage.
6. Provide complete and accurate information (to the extent possible) that PHP and practitioners/providers need in order to provide care.
7. Participate in understanding your health problems and developing treatment goals you agree on with your PHP provider.
8. Follow the plans and instructions for care that you agree on with your PHP provider.
9. Understand what services have deductibles, coinsurance and/or copays, and pay them directly to the network physician, practitioner or provider who gives you care.
10. Read your PHP certificate of coverage and other PHP member materials and become familiar with and follow health plan benefits, policies and procedures.
11. Report health care fraud or wrongdoing to PHP.