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Rights and responsibilities

As a member of Providence Health Plan, you should know what to expect from us, as well as what we ask from you. Nobody knows more about your health than you and your doctor. We take responsibility for providing the very best health care services and benefits possible; your responsibility is to know how to use them well. Please take time to read and understand your benefits. We want you to have a positive experience with Providence Health Plan, and we're ready to help in any way.

Members have the right to:

  • Be cared for by people who respect your privacy and dignity.
  • Be informed about Providence Health Plan, our providers, your rights and responsibilities, and the benefits and services you have available to you as a member.
  • Receive information that helps you select a qualified practitioner whom you trust and with whom you feel comfortable.
  • A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
  • Receive information and clinical guidelines from your health care provider or your health plan that will enable you to make thoughtful decisions about your health care.
  • Actively participate in decisions that relate to your health and your medical care through discussions with your health care provider or through written advance directives.
  • Have access to medical services that are appropriate for your needs.
  • Express a concern about the health plan and receive a timely response from Providence Health Plan.
  • Have your claims paid accurately and promptly.
  • Request a review of any service not approved, and to receive prompt information regarding the outcome.
  • Be informed about and make recommendations regarding Providence Health Plan's member rights and responsibilities policy.
  • Refuse care from specific providers.

Members have the responsibility to:

  • Read and understand the information in and the terms of your contract and call Customer Service if you have questions.
  • Talk openly with your physician or provider, understand your health issue and work toward a relationship built on mutual trust and cooperation.
  • Develop mutually agreed upon treatment goals with your qualified practitioner, to the degree possible, and follow the treatment plans and instructions.
  • Supply to the extent possible medical information Providence Health Plan and your physicians or providers need to provide care. 
  • Do your part to prevent disease and injury. Try to make positive, healthful choices. If you do become ill or injured, seek appropriate medical care promptly.
  • Treat your physicians or providers courteously.
  • Make your required copayment at the time of service.
  • Show your member identification card whenever you receive medical services.
  • Let us know if you have concerns, or if you feel that any of your rights are being compromised, so that we can act on your behalf.
  • Call or write within 180 days of service if you wish to request a review of services provided or appeal a Providence Health Plan decision.
  • Notify Customer Service if your address changes.

Providence Health Plan has the responsibility to:

  • Respect and honor your rights.
  • Ensure timely access to appropriate health care services.
  • Enable you to see physicians or providers who meet your needs.
  • Develop a variety of benefits to serve you well.
  • Assure the ongoing quality of our providers and services.
  • Contract with providers who are capable, competent and committed to excellence.
  • Make it easy and convenient for you to appeal any policy or decision that you believe prevents you from receiving appropriate care.
  • Provide you with accurate up-to-date information about Providence Health Plan and network providers.
  • Provide you with information and services designed to help you maintain good health and receive the greatest benefit from the services we offer.
  • Ensure privacy and confidentiality of your medical records with access according to law.
  • Ensure that your interests are well represented in decisions about Providence Health Plan policy and governance.
  • Encourage physicians and providers to make medical decisions that are always in your best interest.