Member Rights and Responsibilities
1. Confidentiality of Health Care Records
Information from Your medical records and information received from Practitioners/Providers incident to the doctor-patient or Hospital-doctor relationship shall be kept confidential. Except for use incident to bona fide medical research and education or reasonably necessary in connection with the administration of the Prominence Health Plan program, such records may not be disclosed without Your consent.
2. Primary Care Provider (PCP)
Every Prominence Health Plan HMO HealthFirst Member must have a PCP. You have the right to select, or have selected on Your behalf, a PCP from the Prominence HealthFirst In-Network Practitioner/Provider panel. Your PCP will act as the coordinator and manager of Your healthcare needs. If You do not select a PCP, Prominence Health Plan will select one for You.
3. Explanation of Treatment
You have the right to a candid discussion of appropriate or medically necessary treatment options for Your conditions, regardless of cost or benefit coverage. You have the right to participate with Your Practitioners/Providers in making decisions about Your healthcare.
4. Internal Claim and Appeal Procedure
You have the right to voice complaints or appeals about the organization or the care it provides. You have the right to express Your concerns and problems regarding Your Prominence Health Plan coverage and benefits. You are encouraged to contact Customer Service at the phone number on the back of your member ID card with any questions or problems as soon as they arise.
Prominence Health Plan is committed to providing prompt and responsive service to all Members. We have established a Member Complaint and Appeal Procedure to assist You if You have a problem or concern regarding any aspect of Prominence Health Plan services. The Complaint and Appeal Procedure is provided in the Evidence of Coverage and is also available upon request from the Prominence Health Plan Customer Service Department.
5. Notice of Claim
You should not have to make payments for Medically Necessary Covered Services to Prominence Health Plan In-Network Practitioners/Providers except for the required Copayments, Calendar Year Deductible, or Coinsurance. If, however, You have paid for services which are covered, You may be reimbursed providing:
a. You provide Prominence Health Plan with satisfactory evidence that You have properly made such a payment.
b. You make the request for reimbursement within 12 months of the date of service and provide proof of payment. Requests should be submitted to:
Prominence Health Plan
1510 Meadow Wood Lane
Reno, Nevada 89502
6. Healthy Lifestyle
As a Prominence Health Plan Member, You have access to medical care and coverage of medical care as described in your plan EOC or COC. You are encouraged to maintain a healthy lifestyle and to seek medical care when appropriate. You have a responsibility to follow plans and instructions for care that You have agreed to with Your Plan Practitioners/Providers.
7. Maintain Appointments
You have a responsibility to keep the appointment made by or for You with Plan Practitioners and other Providers of care. If You are unable to keep an appointment, always make an effort to notify the In-Network Practitioner/Provider and cancel at least 24 hours in advance. If You do not show up for a scheduled appointment, You may be financially responsible for the applicable copayment.
8. Authorization to Review Records
By receiving benefits under this EOC, You and Your covered Dependents automatically agree to certain conditions. You have a responsibility to supply information (to the extent possible) that the organization and its Practitioners and providers need in order to provide care.
9. Health Responsibility
You have a responsibility to understand Your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible. You have the right to a candid discussion of appropriate or Medically Necessary treatment options for Your medical conditions, regardless of cost or benefit coverage. You have the right to be treated with respect and recognition of Your dignity and right to privacy.
You have the right to receive information about the organization, its services, Practitioners, Providers and the above rights and responsibilities. To obtain information about Practitioners and Providers who participate with Prominence Health Plan, You can call Customer Service at the phone number on the back of your member ID card, or find this information at www.prominencehealthplan.com. You have the right to make recommendations regarding the organization’s Member Rights and Responsibilities policies. The Member has the responsibility to provide, to the extent possible, information that Prominence HealthFirst and its Practitioners/Providers need in order to care for them.
Nevada Division of Insurance
Carson City Office
Consumer Compliance & Licensing
1818 E. College Pkwy., Suite 103
Carson City, Nevada 89706
Las Vegas Office
2501 East Sahara Ave., Suite 302
Las Vegas, NV 89104
Texas Department of Insurance
P.O. Box 149091
Austin, Texas 78714-9091
Division of Insurance Toll Free: 888-872-3234