2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Medicare Advantage Plans New Member Education, Verification, and Welcome Calls .......................... 19-4Medicare Member Appreciation Events ................................................................................................. 19-4Additional Medicare Benefits Medicare Social Service Coordinators ..................................................... 19-4SilverSneakers ® Fitness Program .......................................................................................................... 19-4Members’ Rights and Responsibilities ................................................................................................... 19-5Members have the right to ..................................................................................................................... 19-5Members have the responsibility to: ....................................................................................................... 19-7Confidentiality ........................................................................................................................................ 19-7Member Health Information Rights ........................................................................................................ 19-8Legal Authority to Make Health Care Decisions for Minors or Others .................................................... 19-8Right to See and Get a Copy of Health Information ............................................................................... 19-8Right to Amend Incorrect or Incomplete Health Information ................................................................... 19-8Right to Request Restrictions of Health Information .............................................................................. 19-8Right to Request Confidential Communications of Health Information ................................................... 19-8Right to Request an Accounting of Disclosures ..................................................................................... 19-8Right to Receive a Paper Copy of Privacy Notice .................................................................................. 19-9Use of Consents and Authorizations to Obtain Protected Health Information ........................................ 19-9Members Who are Unable to Give Consent or Authorization ................................................................. 19-9Member Access to Protected Health Information Contained in Plan Records ...................................... 19-10Safeguarding Oral, Written, and Electronic Protected Health Information Across Presbyterian ............ 19-10myPRES/Website Internet Information ................................................................................................ 19-10Protection of Information Disclosed to Plan Sponsors, Employers, or Government Agencies .............. 19-11Cultural Competency ........................................................................................................................... 19-11Translation Services ............................................................................................................................ 19-11Advance Directive ................................................................................................................................ 19-12Provider CARE Unit ............................................................................................................................. 19-13Self-Help Options ................................................................................................................................ 19-13Web-based Inquiries ........................................................................................................................... 19-13Helpful Tips ......................................................................................................................................... 19-14Contacting the Provider CARE Unit ..................................................................................................... 19-14Telephone Inquiries ............................................................................................................................. 19-1420. Appeals and Grievances ......................................................................................................................... 20-1Provider Appeals and Grievance Process .............................................................................................. 20-1Standard Appeal ................................................................................................................................... 20-1Formal Grievances ................................................................................................................................ 20-2Circumstances Giving Rise to a Provider Fair Hearing .......................................................................... 20-2Initiation of an Appeal Hearing............................................................................................................... 20-2Member Appeals and Grievances .......................................................................................................... 20-3xx2014 Practitioner and Provider Manual - Ver. 3