SELECT AN OPTION: Member
1. Know your rights and learn about the health plan’s quality program.
To review your rights and responsibilities as a health plan member and to learn about the health plan’s quality program and goals, please visit your health plan’s website. If you would like a written copy of our quality program or a copy of your rights and responsibilities, please call Customer Service. You may also find a written copy of the Rights and Responsibilities document on the Quality section of your health plan’s website.
2. Read your benefit information.
Your benefit documents are a good source of information. The documents help you understand the benefits and services you have; the benefits and services you don’t have (exclusions); how to get your prescription drugs and what drugs are covered; your share of cost or ways you can pay for health care; what to do if and when you need to submit a claim; how to find out about participating providers; what to do if you need care when you are out of town; how and when to get routine, after-hours, specialty and emergency care; how to voice a complaint or appeal a coverage decision; and how to get care from specialists, hospitals and mental health providers. If you need another copy of this information, please call the Customer Service phone number on your health plan member identification card. You may also find a written copy of general benefit information on your health plan’s website.
3. Know what to do if you have an issue.
We strive to meet your needs. If you are unhappy with services or care, or with the health plan in general, please call Customer Service or write a letter to Health Plan of Nevada. Either way, we will respond to your issue.
4. Know how to get information at your fingertips.
Did you know your health plan has online tools to help you? You can search our electronic provider directory and review the drugs covered on our formulary. As a member, you also have access to information on our programs and services, such as health education and wellness classes and value added services. As always, if you have questions about your plan, call Customer Service.
5. Know that we research new medical technology.
For safety reasons, we formally evaluate new and emerging medical discoveries before including them in our member benefit package. Conducted by a highly-skilled technical staff that includes physicians, our review process evaluates new technology against medical standards and clinical research to assess the effectiveness and safety of new medical procedures, drugs and devices. We also research new applications of existing technologies. If you, your providers or other interested parties would like to submit a request for the review of new medical technology, please contact Customer Service.
6. Ask for help if you speak another language.
If you need help with communication, such as the services of a language interpreter, please call Customer Service.
7. Know that the health plan does not offer incentives for prior authorization denials.
Health Plan of Nevada and Southwest Medical prohibit the compensation of physicians, other health care professionals or staff to be based upon or used as an incentive for the denial of benefits. All decisions regarding your benefits are given special consideration based on your medical needs and the appropriateness of the care and service. Health Plan of Nevada and Southwest Medical employees who perform utilization review duties do not receive any incentives, financial or otherwise, to encourage denial of benefits. That is, we provide no incentive for anyone on our team to restrict benefits for our members. For more information, please call Customer Service.
8. Learn about internal and external review for denial of benefits.
If a benefit is denied, we provide internal review to help ensure member satisfaction in the medical decision-making process. Additionally, external independent review is provided by a panel of impartial medical professionals for eligible denials that have already undergone internal review. Expedited appeals are available when decisions are needed quickly. For additional information, please refer to your plan documents or call Customer Service.
9. Know that we have special programs available for members.
Are you looking for extra help? You may be eligible for additional benefits from one of the programs below.
10. Know that we evaluate the care you receive.
If you are admitted to a non-contracted facility or receive care or services outside of the Health Plan of Nevada service area, we may perform a retrospective review (after care was received) to evaluate the appropriateness of the medical care, services, treatments and procedures you received. As part of this process, we will review your medical records, admitting diagnosis and presenting symptoms. Keep in mind, access to nonemergency care outside of the contracted provider network or service area may not be covered and may incur additional expense for you or your family.
11. We want to hear from you.
You may get a survey in the mail about your health plan. We need your help so we can monitor our plan and make improvements for our members. Surveys you may get include the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Health Outcomes Survey (HOS) for Medicare members, Patient Satisfaction Survey, Disease Management Program Satisfaction Survey, Complex Case Management Program Satisfaction Survey and Telephone Advice Nurse Program Satisfaction Survey. Members are randomly selected for these surveys. If you get one, please fill it out. Your input is valuable to us.
12. Make an investment in your future.
It’s one that pays solid dividends, too. Keeping up with recommended health screenings may help your primary care physician take care of the little things — before they become more serious. At your next appointment, please talk to your primary care physician about screenings and recommendations. Depending on your medical history, your provider may have additional medical advice. You can find the preventive services here.
Call Customer Service at the toll-free number listed on the back of your member ID card or visit SeniorDimensions.com.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change on January of each year. Other providers are available in our network. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.