Members Rights Policy

The KEY Medical Group Member has the right to:

• Receive care regardless of member race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical conditions, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment and that they will be accepted for treatment.
• Have services provided in a nondiscriminatory manner.
• Be provided with comprehensible information about the KEY Medical Group, its services, providers and the health care service delivery process. This information includes instructions on how to obtain care with various providers and at varied facilities (e.g., primary care, specialty care, behavioral health services, hospital services.) Additionally, information will be included on how to obtain services outside the KEY Medical Group system or service area.
• Be informed regarding KEY Medical Group prior authorization guidelines, review process and rules.
• Be informed of emergent and non-emergent benefit coverage and cost of care, and receive an explanation of the member’s financial obligations as appropriate, prior to incurring the expense (including co-payments, deductibles, and co-insurance).
• Be provided with information on how to obtain care after normal office hours and how to obtain emergency care including when to directly access emergency care or use 911 services.
• Examine and receive an explanation of bills generated for services delivered to the member.
• Be provided with information on how to submit a claim for covered services.
• Be provided with information on prior authorization and review guidelines.
• Be informed of the name and qualifications of the physician who has primary responsibility for coordinating the member’s care; and be informed of the names, qualifications, and specialties of other physicians and non-physicians who are involved in the member’s care.
• Have 24-hour access to the member’s primary care physician (or covering physician).
• Receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, and prospects for recovery in terms that are understandable to the member, in order to give informed consent or to refuse that course of treatment.
• Candidly discuss appropriate or medically necessary treatment options for the member’s condition, regardless of cost or benefit coverage.
• Actively participate in decisions regarding the member’s health care and treatment plan. To the extent permitted by law, this includes the right to refuse any procedure or treatment. If the recommended procedure or treatment is refused, an explanation will be given addressing the effect that this will have on the member’s health.
• Review their medical records and provide the healthcare provider a written addendum with respect to any item or statement in the record that the member believes is incomplete or incorrect.
• Be treated with respect and dignity.
• Receive considerate and respectful care with full consideration of the member’s privacy.
• Receive confidential treatment of all member information and records used for any purpose.
• Be informed of applicable rules in the various health care settings regarding member conduct.
• Express opinions or concerns about the KEY Medical Group or the care provided and offer recommendations for change in the health care service delivery process by contacting the KEY Medical Group Member Services Department.
• Be informed of the member complaint/grievance and appeal process including how to express a complaint or appeal.
• Be informed of the termination of a primary care provider or practice site and receive assistance in selecting a new primary care provider or site in this situation.
• Change primary care physicians by contacting the Member Services Department.
• Be provided with information on how the KEY Medical Group evaluates with health plans, new technology for inclusion as a covered benefit.
• Receive reasonable continuity of care and be given timely and sensible responses to questions and requests made for service, care and payment (including complaints and appeals).
• Be informed of continuing health care requirements following office visits, treatments, procedures and hospitalizations.
• Members have the right to be represented by parents, guardians, family members or other conservators for those who are unable to fully participate in their treatment decisions. All member rights apply to the person who has the legal responsibility to make health care decisions for the member.
• Make recommendations regarding KEY Medical Group’s member’s rights and responsibilities policies.
• Members have the right to request a free copy of the actual benefit provision, guideline, protocol or other similar criteria on which a medical decision was based upon by calling Key Medical Group, Inc. at (559) 734-1321

Member Responsibilities Policy

The KEY Medical Group Member has the responsibility to:

• Provide the member’s health care provider with complete and accurate information which is necessary for the care of the member (to the extent possible).
• Be on time for all appointments and notify the provider’s office as far in advance as possible for appointment cancellation or rescheduling.
• Report changes in the member’s condition according to provider instructions.
• Inform providers of the member’s inability to understand the information given to him/her.
• Carry out the treatment plan which has been developed and agreed upon by the health care provider and the member.
• Contact the member’s primary care physician (or covering physician) for any care which is needed after that physician’s normal office hours.
• Treat the health care providers and staff with respect.
• Obtain an authorized referral from the member’s primary care physician for a visit to a specialist and/or to receive any specialty care.
• Be familiar and comply with the KEY Medical Group’s health care service delivery system regarding access to routine, urgent and emergent care.
• Contact the KEY Medical Group Member Services Department or the member’s Health Plan Member Services Department regarding questions and assistance.
• Respect the rights, property and environment of all physicians and KEY Medical Group providers, staff and other members.
• Understand their health problems and participate in developing mutually agreeable treatment goals to the fullest extend possible.
• Have all of these responsibilities apply to the person who has the legal responsibility to make health care decisions for the member.