PPO member rights and responsibilities

As a member of our Preferred Provider Organization (PPO), you have certain rights and responsibilities. The success of your treatment and your satisfaction depends, in part, on you taking responsibility as a patient. Acquainting yourself with your rights and responsibilities will help you take a more active role in your health care.

You have a right

  • To be treated with respect and recognition of your dignity and right to privacy at all times, to receive considerate and respectful care regardless of religion, race, national origin, age, gender, or financial status.
  • To receive information about Capital Blue Cross, its services, its contracted practitioners and providers (including information regarding a provider’s qualifications, such as medical school attended, residency completed, or board certification status), and member rights and responsibilities. Members can call Member Services to obtain this information.
  • To make recommendations to the list of member rights and responsibilities.
  • To have Capital Blue Cross member literature and material for the member’s use, written in a manner which truthfully and accurately provides relevant information that is easily understood.
  • To know the name, professional status, and function of those involved in your care.
  • To obtain from your physician complete current information concerning your diagnosis, treatment, and prognosis in terms you can reasonably understand, unless it is not medically advisable to provide such information.
  • To candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
  • To participate with practitioners in decision making regarding your health care.
  • To know what procedure and treatment will be used so that when you give consent to treatment, it is truly informed consent. Members should be informed of any side effects or complications that may arise from proposed procedures and treatment in addition to possible alternative procedures. Your physician is responsible for providing you with information you can understand.
  • To be advised if any experimentation or research program is proposed in your case and of your right to refuse participation.
  • To refuse any drugs, treatment, or other procedure offered to you to the extent permitted by law and to be informed by your physician of the medical consequences of such refusal.
  • To all information contained in your medical record unless access is specifically restricted by the attending physician for medical reasons.
  • To expect that all records pertaining to your medical care are treated as confidential unless disclosure is necessary for treatment, payment, and operations.
  • To be afforded the opportunity to approve or refuse release of identifiable personal information except when such release is allowed or required by law.
  • The right to file dissatisfaction about us or the care rendered by your provider and to file an appeal from an adverse benefit determination or final internal adverse benefit determination.

You have a responsibility

  • To follow the rules of membership and to read all materials carefully.
  • To carry your Capital Blue Cross ID card with you and present it when seeking health care services.
  • To provide Capital Blue Cross with relevant information concerning any additional health insurance coverage which you or any of your dependents may have.
  • To timely notify Capital Blue Cross and your employer of any changes in your membership, such as change of address, marital status, etc.
  • To seek and obtain services from the Primary Care Physician (PCP) you have chosen, as well as direct access to obstetrical/gynecological care and in emergencies or when your chosen physician has referred them to other participating providers and/or Capital Blue Cross has preauthorized you to do so.
  • To communicate openly with the physician you choose by developing a physician-patient relationship based on trust and cooperation.
  • To follow the plans and instructions for care that you have agreed upon with your practitioner.
  • To ask questions to make certain you understand the explanations and instructions you are given.
  • To understand your health problems and participate, to the degree possible, in developing mutually agreed upon treatment goals.
  • To understand the potential consequences if you refuse to comply with treatment plans or recommendations.
  • To keep scheduled appointments or give adequate notice of delay or cancellation.
  • To pay appropriate copayments and coinsurance to providers when services are received.
  • To keep Capital Blue Cross informed of any concerns regarding the medical care you receive.
  • To provide, to the extent possible, information that Capital Blue Cross and its practitioners and providers need in order to facilitate and provide care and administer your coverage.
  • To treat others with respect and recognition of dignity, and to provide considerate and respectful interaction with others regardless of their religion, race, national origin, age, or gender.