22.

RIGHTS AND RESPONSIBILITIES

A. Members’ Rights and Responsibilities

APPLIES TO:

A. This policy applies to all IEHP Medi-Cal Members.

POLICY:

A. For the purpose of this policy, a “Delegate” is defined as a medical group, IPA or any
contracted organization delegated to provide services to IEHP Members.
B. Members have the right to quality care when accessing services covered by IEHP. IEHP
believes that Members, Providers, practitioners, and Delegates have a role in assuring the
quality of care received.
C. IEHP adopted and continues to use the “Consumer Bill of Rights and Responsibilities,”
promulgated by the President of the United States, as the basis for its statement of
Members’ Rights and Responsibilities.
D. IEHP requires Providers and practitioners to understand and abide by IEHP’s Members’
Rights and Responsibilities when providing services to Members.
E. IEHP informs Members of their Members’ Rights and Responsibilities in the Member
Handbook upon enrollment and annually thereafter or upon request in a manner
appropriate to their condition, individual communication style, and ability to understand.
F. It is IEHP’s policy to respect and recognize Members’ rights. The following statements
are included in the Member Handbook.
1. As a Member of IEHP, you have the right to:
a. Receive information about your rights and responsibilities as an IEHP
Member.
b. Be treated with respect and courtesy. IEHP recognizes your dignity and
right to privacy.
c. Receive information about IEHP, its programs and services, its Doctors,
its Providers, and health care facilities.
d. Receive information about IEHP staff and staff qualifications for disease
management programs.
e. Receive information on how to reach Disease Management staff and to
discuss any problems regarding Disease Management and how to request a
change.
f. Receive interpreter services at no cost to you.
g. Not be charged by your IEHP Doctor for covered health care services,
except for required co-payments.

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h. Receive medically necessary covered services without regard to race,

religion, age, gender, national origin, mental and physical disability,
sexual identity or orientation, genetic information, source of payment,
family composition or size, or medical condition or stage of illness.
i. Receive family planning services, services at Federally Qualified Health
Centers or Indian Health Centers, sexually transmitted disease (STD)
services, and emergency services outside the IEHP network as stated in
Federal law (Medi-Cal Members).
j. If you are under a Doctor’s care for an acute condition, serious chronic
condition, pregnancy, terminal illness, newborn care, or a scheduled
surgery, you may ask to continue seeing your current Doctor. To make this
request, or if you have any concerns about your continuity of care, please
call IEHP Member Services at 1-800-440-IEHP (4347) /TTY 1-800-718-
4347.
k. If you have been receiving care from a Health Care Provider, you may
have a right to keep your Provider for a designated time period. Please
contact IEHP Member Services at 1-800-440-IEHP (4347) /TTY 1-800-
718-4347. If you have further questions, you are encouraged to contact the
Department of Managed Health Care (DMHC), which protects HMO
consumers, by telephone at its toll free number, 1-888-HMO-2219, or at a
TTY number for the hearing impaired at 1-877-688-9891, or online at
www.hmohelp.ca.gov.
l. Receive emergency or urgently needed services outside the IEHP network.
m. Receive emergency care whenever necessary and wherever you need it.
n. Receive sensitive services, such as family planning or mental health care
in a confidential way.
o. Access minor consent services (Medi-Cal).
p. Choose a Primary Care Doctor within the IEHP network.
q. If your Primary Care Doctor changes, your IEHP benefits and required co-
payments will stay the same.
r. Receive information from IEHP that you can understand.
s. Receive Member informing materials in alternative formats, including
Braille, large print, and audio.
t. Make recommendations about IEHP Members’ rights and responsibilities
policies.
u. Participate with Doctors in decision making about your own health care.

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A. Members’ Rights and Responsibilities

v. Talk with your Doctor about your medical condition and appropriate or
medically necessary treatment options regardless of the cost or what your
benefits are. Members who are not able to talk with their doctor about
decision making have the right to be represented by parents, guardians,
family members or other conservators.
w. Decide about your care, including the decision to stop treatment, services,
or stop participating in disease management programs.
x. Decide in advance how you want to be cared for in case you have a life-
threatening illness or injury.
y. Be informed by IEHP regarding advance directives, and to receive
information from IEHP regarding any changes to that law. The
information shall reflect changes in state law regarding advance directives
as soon as possible, but no later than ninety (90) days after the effective
date of change.
z. Review, request corrections to, and receive a copy of your medical records
(your Doctor may charge a fee for copies of records and other forms).
aa. Keep your personal and medical information, and records confidential,
unless you say differently, and know how IEHP keeps your information
confidential.
bb. Complain about IEHP, its Providers, or your care. IEHP will help you
with the process. You may appeal decisions made by IEHP or your
Medical Group. You have the right to choose someone to represent you
during the grievance process and for your complaints and appeals to be
reviewed as quickly as possible and be told how long it will take. Medi-
Cal Members have the right to request a State Fair Hearing or an
expedited Fair Hearing for urgent cases. Call the Department of Social
Services Public Inquiry and Response Unit at 1-800-952-5253 or TTY
1-800-952-8349.
cc. Have IEHP act as your patient advocate.
dd. Be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience, or retaliation.
ee. Medi-Cal recipients can stop being IEHP Members (disenroll) at anytime,
for any reason. If you want to disenroll, call IEHP Member Services at
1-800-440-IEHP (4347)/TTY 1-800-718-4347 or Health Care Options at
1-800-430-4263 to get disenrollment information.
ff. IEHP will honor authorizations for services already approved for you. If
you have any authorizations pending approval, if you are in the middle of
treatment, or if specialty care has been scheduled for you by your current
Doctor, contact IEHP to help you coordinate your care during this

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A. Members’ Rights and Responsibilities

transition time. Call IEHP Member Services at 1-800-440-IEHP (4347)

/TTY 1-800-718-4347.
gg. Request a second opinion about a medical condition.
hh. File a grievance with IEHP if your linguistic needs are not met.
ii. Request an Independent Medical Review from the Department of
Managed Health Care (DMHC) within six (6) months, if you disagree with
IEHP’s decision to deny, delay, or modify a service your Doctor requests.
jj. Request an External Independent Review from IEHP and/or an
Independent Medical Review from the Department of Managed Health
Care (DMHC) if a service or a therapy was denied on the basis that it was
considered experimental or investigational. If you have any questions
about these procedures, call IEHP Member Services at 1-800-440-IEHP
(4347) /TTY 1-800-718-4347.
kk. If you are a Native American Indian, you have the right to not enroll in a
plan, not be restricted by a plan in your right to access Indian Health
Facilities, and to disenroll from a plan without cause.
G. It is IEHP’s policy that Members have certain responsibilities. The following statements
are included in the Member Handbook.
1. As a Member of IEHP, you have the responsibility to:
a. Be familiar with and ask questions about your health plan options, your
health plan coverage limitations and exclusions, rules about the use of
network Providers, coverage and referral rules, appropriate process to
obtain additional information, and process to appeal coverage decisions.
If you have a question about your coverage, call IEHP Member Services at
1-800-440-IEHP (4347)/TTY (800) 718-4347.
b. Follow the advice and care procedures indicated by your doctor, IEHP and
the program. If you have a question about these procedures, call IEHP
Member Services at 1-800-440-IEHP (4347)/TTY 1-800-718-4347.
c. Request interpreter services at least five (5) working days before a
scheduled appointment.
d. Call your Doctor or pharmacy at least three (3) days before you run out of
medicine.
e. Cooperate with your Doctor and staff and treat them and other patients
with respect. This includes being on time for your visits or calling your
Doctor if you need to cancel or reschedule an appointment.
f. Understand that your Doctor’s office may have limited seating for patients
and caregivers only.

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A. Members’ Rights and Responsibilities

g. Give accurate information to IEHP, your Doctor, and any other Provider.
This helps you receive better care.
h. Understand your health care needs and be a part of your health care
decisions. Ask your Doctor questions if you do not understand.
i. Work with your Doctor to make plans for your health care.
j. Follow the plans of care and any other Provider instructions your Health
Care Providers feels is necessary.
k. Notify IEHP and your Doctor if you want to stop the plans and
instructions you have agreed on or want to stop participating in health
management programs.
l. Immunize your children by age 2 years and always keep your children’s
immunizations up to date.
m. Call your Doctor when you need routine or urgent health care.
n. Care for your own health. Live a healthy lifestyle, exercise, eat a good
diet, and don’t smoke.
o. Avoid knowingly spreading disease to others.
p. Use IEHP’s grievance process to file a complaint. Call IEHP Member
Services at 1-800-440-IEHP (4347) / TTY 1-800-718-4347 to file a
complaint (grievance or appeal).
q. Report any wrongdoing or fraud to IEHP by calling the Compliance
Hotline at 1-866-355-9038, or the proper authorities.
r. Understand that there are risks in receiving health care and limits to what
can be done for you medically.
s. Understand that it is a Health Care Provider’s duty to be efficient and fair
in caring for you as well as other patients.
t. Make a good-faith effort to pay your health care bills (Premiums, co-pays
and non-covered services where applicable).
u. Follow administrative and operational procedures of IEHP, its Providers
and Government health benefit programs.

PROCEDURES:

A. Members’ Rights and Responsibilities notification procedures include:

1. Members’ Rights and Responsibilities are communicated to new Members
through the Post-Enrollment Kits that contain the Member Handbook. The
Member Handbook is mailed to all heads of household annually thereafter. The

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22. RIGHTS AND RESPONSIBILITIES

A. Members’ Rights and Responsibilities

Member Handbook contains IEHP’s statement of Members’ Rights and

Responsibilities.
2. Members’ Rights and Responsibilities can be found posted on the IEHP web site
at www.iehp.org. Any updates to the Member’s Rights and Responsibilities are
provided in quarterly Member newsletters.
3. Members’ Rights and Responsibilities, including the grievance and appeals
process, are communicated to all IEHP practitioners through the annual update
and distribution of the IEHP Policy and Procedure Manual. New practitioners
receive the IEHP Policy and Procedure Manual within the first month of joining
IEHP. Information on policy changes or updates may be included in Provider
Newsletters.
4. IEHP staff who have direct contact with Members are trained on Members’
Rights and Responsibilities, including the grievance system, and are able to
communicate those rights and responsibilities effectively.
B. Providers and practitioners are encouraged to help Members understand their rights and
responsibilities as outlined above, encourage Members to appropriately utilize their
covered benefits, and encourage Members to contact IEHP Member Services at
1-800-440-IEHP (4347)/TTY 1-800-718-4347 if they have questions concerning their
benefits.
C. Grievance Rights:
1. Members have the right to file a grievance with either the Provider, practitioner,
or with IEHP. Members are encouraged to speak with their practitioner first.
Providers and practitioners are required to maintain copies of IEHP’s Member
Complaint Form and to give copies to Members when requested. Providers and
practitioners are also required to immediately forward to IEHP any grievances
filed by a Member. If a Member needs assistance filling out the form or wishes to
file a grievance directly with IEHP, he/she should call IEHP Member Services at
1-800-440-IEHP (4347)/TTY 1-800-718-4347. Members may file a grievance in
person at 10801 Sixth St. Suite 120, Rancho Cucamonga, CA 91730 or by mail to
the IEHP Grievance Unit, P.O. Box 1800, Rancho Cucamonga, CA 91729-1800.
Members may also file a grievance through IEHP’s web site at www.iehp.org, or
via facsimile at (909) 890-5748, Attention: Grievance Department.
2. The following grievance rights are included in the Member handbook:
a. If your grievance concerns are a serious threat to your health, we will
resolve it within seventy-two (72) hours. All other grievances are resolved
within thirty (30) days.
b. You have the right to ask IEHP to help you work with your Provider or
anyone else to fix your problem.
c. You have the right to change your Providers.

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A. Members’ Rights and Responsibilities

d. You have the right to ask a relative or someone else to help file your
grievance and represent you during the grievance process. Grievances can
be registered or filed by Parents, Guardians, Conservator, Relative,
Doctor, or other Designee if the Member is a minor or an adult who is
otherwise incapacitated. Relatives include Parents, Stepparents, Spouse,
Adult Son or Daughter, Grandparents, Brother, Sister, Uncle, or Aunt.
e. You have the right to disenroll from IEHP without giving a reason.
f. You have the right to request voluntary mediation. A third party unrelated
to Member or IEHP considers all aspects or issues and takes measures to
reach the best decision for both you and IEHP. You and IEHP will share
the cost of the mediation. You do not need to participate in the voluntary
mediation process for any longer than thirty (30) days prior to submitting a
complaint to the DMHC.
g. You have the right to submit written comments, documents or other
information in support of your grievance.
h. You may contact other State Agencies for help. See the Grievance and
Appeals Process Section in the Member Handbook.
3. The following information is included in the Member Handbook, grievance letters
and denial letters:
a. DMHC is responsible for regulating health care service plans. If you have
a grievance against your health plan, you should first telephone your
health plan at 1-800-440-IEHP (4347)/TTY 1-800-718-4347 and use your
health plan’s grievance process before contacting the department.
Utilizing this grievance procedure does not prohibit any potential legal
rights or remedies that may be available to you. If you need help with a
grievance involving an emergency, a grievance that has not been
satisfactorily resolved by your health plan, or a grievance that has
remained unresolved for more than thirty (30) days, you may call the
department for assistance. You may also be eligible for an Independent
Medical Review (IMR). If you are eligible for IMR, the IMR process will
provide an impartial review of medical decisions made by a health plan
related to medical necessity of a proposed service or treatment, coverage
decisions for treatments that are experimental or investigational in nature
and payment disputes for emergency or urgent medical services. The
department also has a toll-free telephone number (1-888-HMO-2219) and
a TTY line (1-877-688-9891) for the hearing and speech impaired. The
department’s Internet Web site http://www.hmohelp.ca.gov has
complaint application forms and instructions online.
b. Medi-Cal Members also have the right to request a Medi-Cal State Fair
Hearing at any time, regardless of whether a complaint has been filed with

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A. Members’ Rights and Responsibilities

the Provider or IEHP, by calling the Department of Social Services Public

Inquiry and Response unit at 1-800-952-5253 or TTY 1-800-952-8349 or
by mail at California Department of Social Services, State Hearings
Division, P.O. Box 944243, Mail Station 9-17-37, Sacramento, CA 94244-
2430.
c. Authorized Representative: IEHP Medi-Cal Members may represent
themselves at the Medi-Cal State Fair Hearing. If they choose, a friend, an
attorney, or any other person can represent them, but they must arrange
this themselves. The Public Inquiry and Response Unit at 1-800-952-5253
can help the Member find free legal help.
4. For further information on IEHP’s Grievance Processes, see Section 16,
“Grievance Resolution System.”
REFERENCES:

A. DHCS Contract 04-35765, Amendment 10, Exhibit A, Attachment 13

B. Presidents “Consumer Bill of Rights and Responsibilities”

INLAND EMPIRE HEALTH PLAN

Chief Approval: Signature on file Original Effective Date: September 1, 1996

Chief Title: Chief Executive Officer Revision Date: July 1, 2015

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22. RIGHTS AND RESPONSIBILITIES

B. Providers’ Rights and Responsibilities

APPLIES TO:

A. This policy applies to all IEHP Medi-Cal Providers

POLICY:
A. All Network Practitioners, including those contracted directly with IEHP, are
obligated to participate in and work with IEHP programs, services, standards,
policies and procedures required by IEHP.
B. Practitioners have the right to know what they can expect when working with
IEHP.
C. It is IEHP policy to respect and recognize all practitioners’ rights as follows:
1. As a Practitioner within the IEHP network, you have the right to:
a. Receive information about IEHP, including available programs and
services, its staff and its staff qualifications, operational
requirements, and any contractual relationships;
b. Receive information about how IEHP coordinates its interventions
with treatment plans for individual patients;
c. Receive support from IEHP to make decisions interactively with
patients regarding their health care;
d. Receive contact information for staff responsible for managing and
communicating with the practitioner’s patients;
e. Receive clinical performance data and Member experience data or
results, as applicable when requested.
f. Receive courteous and respectful treatment from IEHP staff; and,
g. Complain about IEHP, including but not limited to: staff, policies,
processes and procedures utilizing IEHP Practitioner Grievance
and Appeal Resolution Process.
2. It is IEHP policy that all practitioners directly contracting with IEHP have
the following credentialing rights:
a. Review information submitted to support your credentialing
application;
b. Correct erroneous information during the credentialing process;
c. Be informed of the status of your credentialing or recredentialing
application upon request; and
d. Be notified of these credentialing rights.
D. It is IEHP policy that practitioners’ have certain responsibilities.
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22. RIGHTS AND RESPONSIBILITIES

B. Providers’ Rights and Responsibilities

1. As a practitioner contracting with the IEHP network, you have the

responsibility to:
a. Be familiar with, ask questions about and comply with all IEHP
Policies and Procedures; and
b. Comply with all regulations and medical standards set forth by the
appropriate regulatory agencies to ensure appropriate medical care
is provided to all IEHP Members.
PROCEDURES:
A. Practitioners are notified of their rights and responsibilities as follows:
1. Practitioner’s rights and responsibilities are communicated in the
practitioner’s contractual agreement with IEHP and/or other Provider
entities within the IEHP network;
2. New Practitioners receive the IEHP Policy and Procedure Manual; and
Benefit Manual within the first month of joining IEHP;
3. Practitioners can access on the IEHP website at www.iehp.org interim
Manual updates as changes to existing policies and procedures and/or new
policies and procedures arise throughout the year;
4. Practitioners receive bi-annual Provider Newsletters to communicate new
ideas, information, program, benefit, policies or regulatory changes; and
5. Changes to policies and programs as well as new policies and programs
are communicated to practitioners through written correspondence, such
as letters and memos, are also posted on the IEHP website, as applicable.
B. Practitioners may communicate with IEHP regarding any complaints, issues or
concerns they may have in relation to the above rights and responsibilities, as
outlined in Section 16B, “Dispute and Appeal Resolution Process for Providers”
of the IEHP Policy and Procedure Manual. Ways to communicate with IEHP may
include:
1. IEHP Provider Relations Team at (909) 890-2054.
2. IEHP Website – www.iehp.org
3. Provider Services Representative (PSRs)
4. providerservices@iehp.org
C. Practitioners are informed of the consequences of failing to comply with the
above rights and responsibilities within the IEHP Provider Policy and Procedure
Manual in addition to their contractual agreement.

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B. Providers’ Rights and Responsibilities

INLAND EMPIRE HEALTH PLAN

Chief Approval: Signature on file Original Effective Date: August 1, 2002

Chief Title: Chief Executive Officer Revision Date: July 1, 2014

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