KP Member Rights

10/24/20

KP Member Rights

Your rights and responsibilities

Colorado

About your rights and responsibilities

We are partners in your health care. Your participation in your health care decisions and your willingness to communicate with your doctor and other health professionals help us in providing you with appropriate and effective health care. We want to make sure you receive the information you need to make decisions about your health care. We also want to make sure your rights to privacy and to considerate and respectful care are honored.

As a member of Kaiser Permanente, you have the right to receive information about your rights and responsibilities and to make recommendations about our member rights and responsibilities policies.

Your rights as a Kaiser Permanente member:

You have the right to:

Participate in your health care.
This includes the right to receive the information that you need to accept or refuse a recommended treatment. Emergencies or other circumstances occasionally may limit your participation in a treatment decision. In general, however, you will not receive medical treatment before you or your legal representative give consent. You have the right to be informed and to decide if you want to participate in any care or treatment that is considered educational research or human experimentation.

Express your wishes concerning future care.
You have the right to choose a person to make medical decisions for you and to express your choices about your future care, if you are unable to do so yourself. These choices can be expressed in documents, such as a durable power of attorney for health care, a living will, or a CPR directive. Inform your family and your doctor of your wishes and give them copies of documents that describe your wishes concerning future care.

Receive the medical information you need to participate in your health care.
This information includes the diagnosis, if any, of a health complaint, the recommended treatment, alternative treatments, and the risks and benefits of the recommended treatment. We will make this information as clear as possible to help you understand it. You are entitled to an interpreter, if you need one. You also have the right to review and receive copies of your medical records, unless the law restricts our ability to make them available. You have the right to participate in making decisions involving ethical issues that may arise during the provision of your care.

Receive information about the outcomes of care you have received, including unanticipated outcomes.
When appropriate, family members or others you have designated will receive such information.

Receive information about Kaiser Permanente as an organization, its practitioners, providers, services, and the people who provide your health care. You are entitled to know the name and professional status of the individuals who provide your service or treatment.

Receive considerate, respectful care. We respect your personal preferences and values.

Receive care that is free from restraint or seclusion. We will not use restraint or seclusion as a means of coercion, discipline, convenience, or retaliation.

Have a candid discussion of appropriate or medically necessary treatment options for your condition(s). You have the right to this discussion, regardless of cost or benefit coverage.

Have impartial access to treatment. You have the right to all medically indicated treatment that is a covered benefit, regardless of your race, religion, sex, sexual orientation, national origin, cultural background, disability, or financial status.

Be assured of privacy and confidentiality. You have the right to be treated with respect and dignity. We will honor your need for privacy and will endeavor not to release your medical information without your authorization, except as required or permitted by law.

Have a safe, secure, clean, and accessible environment.

Choose your physician. You have the right to select and to change physicians within the Kaiser Permanente Health Plan. You have the right to a second opinion by a Kaiser Permanente physician. You have the right to consult with a non-Kaiser Permanente physician at your expense.

Know and use member satisfaction resources. You have the right to know about resources such as patient assistance, member service and grievance and appeals committees, which can help you answer questions and resolve problems. You have the right to make complaints and appeals without concern that your care will be affected. Your membership benefits booklet (Evidence of Coverage or Membership Agreement) describes procedures to make formal complaints. We welcome your suggestions and questions about Kaiser Permanente, our services, our health professionals, and your rights and responsibilities.

Review, amend, and correct your medical records as needed.

Your responsibilities as a Kaiser Permanente member

You have the responsibility to:

Know the extent and limitations of your health care benefits. An explanation of these is contained in your Evidence of Coverage or Membership Agreement.

Identify yourself. You are responsible for your membership card, for using the card only as appropriate, and for ensuring that other people do not use your card. Misuse of membership cards may constitute grounds for termination of membership.

Keep appointments. You are responsible for promptly canceling any appointment that you do not need or cannot keep.

Provide accurate and complete information. You are responsible for providing accurate information about your present and past medical conditions, as you understand them. You should report unexpected changes in your condition to your doctor.

Understand your health problems and participate in developing mutually agreed upon treatment goals to the degree possible.

Follow the treatment plan on which you and your health care professional agree. You should inform your doctor if you do not clearly understand your treatment plan and what is expected of you. If you believe you cannot follow through with your treatment, you are responsible for telling your doctor.

Recognize the effect of your lifestyle on your health. Your health depends not only on care provided by Kaiser Permanente, but also on the decisions you make in your daily life, such as smoking or ignoring care recommendations.

Be considerate of others. You should be considerate of health professionals and other patients. Disruptive, unruly, or abusive conduct may constitute grounds for termination of membership. You should also respect the property of other people and of Kaiser Permanente.

Fulfill financial obligations. You are responsible for paying on time any money you owe Kaiser Permanente. Nonpayment of amounts owed may constitute grounds for termination of membership.

Contacting us about your rights and responsibilities

Kaiser Permanente's member rights and responsibilities statement is reviewed the first of each year.
If you require a paper copy, please call Member Services and we will provide a copy to you. You can also pick up a copy of the Member Resource Guide at any medical office, which contains your member rights and responsibilities.

Denver/Boulder: 303-338-3800 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

Mountain Colorado: 1-844-837-6884 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

Northern Colorado: 1-844-201-5824 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

Southern Colorado: 1-888-681-7878 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

Member Services

Customer satisfaction is a core value at Kaiser Permanente, as well as a necessity for a successful organization. The right to voice dissatisfaction about any aspect of Kaiser Permanente services is one that is protected by both federal and state laws, as well as NCQA accreditation standards.

Member Services is the department that documents, reports, and facilitates the response to member complaints. Member Services also answers general questions about benefits, billing, claims, utilization management processes, hours of operation, and services.

Denver/Boulder: 303-338-3800 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

Mountain Colorado: 1-844-837-6884 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

Northern Colorado: 1-844-201-5824 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

Southern Colorado: 1-888-681-7878 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

Access to Member Services is also available online by email or in writing at:

    Kaiser Permanente
    Member Services Department
    2500 South Havana Street
    Aurora, Colorado 80014-1622

Customer satisfaction procedure

If you are not satisfied with the services received at a particular medical office, or if you have a concern about the personnel or some other matter relating to services and wish to file a complaint, you may do so by following the procedures listed below. We want you to be satisfied with our plan, our plan facilities, services, and physicians. By using this customer satisfaction procedure, you give us the opportunity to correct any problems that keep us from meeting your expectations and your health care needs. If you are dissatisfied for any reason or feel that you have been denied a service or benefit, please let us know.

Denver/Boulder service area

After you notify us of a complaint, this is what happens:

A Member Services liaison reviews the complaint and conducts a thorough investigation, verifying all the relevant facts.

The Member Services liaison or a physician evaluates the facts and makes a recommendation for corrective action, if any.

Member Services responds to oral and written complaints within 30 calendar days.

If you are dissatisfied with the resolution, you have the right to request a second review. Please put your request in writing to:

    Kaiser Permanente
    Member Services Department
    2500 South Havana Street
    Aurora, Colorado 80014-1622

Your written request will be reviewed by Member Services Administration or their designee, who will respond to you in writing within 30 calendar days of the receipt of your request.

Appeals

Review of adverse organization determinations is managed by Appeals Analysts in the Quality, Risk and Legal Department.

All members (or their designee) have the right to request an appeal. Time frames and processes are governed by the type of plan the member has. The member's coverage will determine the regulations under which the appeal will be processed. For example, regulations differ for Medicare enrollees, federal government employees, and commercial group members.

Appeals involving a clinical or medical necessity determination will be reviewed by a physician reviewer. The Physician Reviewer consults with a physician with the appropriate expertise who was not involved in the initial determination and who is not subordinate to the initial decision maker, and whose specialty is the same or is in similar specialty that would typically manage the patient's care. Any denial of an appeal involving a medical necessity issue must be signed by a physician.

After completing the first level of this internal review process, a commercial member can request a Voluntary Second Level appeal; or an additional review by an outside, independent reviewer if the denial is based on medical necessity, efficacy; investigational; or experimental as provided for by federal or state law, accreditation rules, or regulations. Individual members in a non-grandfathered plan are entitled to only one level of internal appeal and may then request independent external review if their appeal meets the criteria for medical necessity reviews.

In situations involving an "urgent" medical condition, members may request an expedited appeal, and may in some situations request simultaneous expedited internal and external review. An independent external appeal may also be available following a contractual denial where the member presents documentation from a medical professional that there is a reasonable medical basis that the contractual limitation may not apply.

For Medicare Advantage members, if an initial adverse determination is upheld by the Appeals Department, the appeal will automatically be forwarded for review by an Independent External Review Entity (IRE) designated by the Centers for Medicare & Medicaid Services.

For Medicare Part D appeals the member is notified of their right to request further review by an Independent External Review Entity (IRE) designated by the Centers for Medicare & Medicaid Services.

Language services are available in accord with federal and state regulatory requirements:

Oral interpretation of a document written in English into member's preferred language. Member notification documents available in languages other than English. Language line interpretation services available for registering oral appeals.

end of document

Centura

Centura Patient Rights from their web site.

Medicare Complaint Form

Medicare Complaint Form from their web site.

-- End of Letter --

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