Useful health plan information

The following information provides a useful guide to our programs, requirements, policies and guidelines. If you would like copies of any of this information sent to you, please contact us.

 Electronic transactions

Learn about our electronic transaction options and enroll to receive your claim vouchers and payments electronically.

 Member rights and responsibilities

Members have the right to:

  • Receive information about our company and services, as well as the physicians, dentists, other health care professionals and facilities (providers) in our network.
  • Receive information about your member rights and responsibilities.
  • Make recommendations regarding our company's rights and responsibilities policy.
  • Be treated with respect and dignity.
  • Privacy of your personal information.
  • Participate in decisions about your care with your doctor and other health care professionals.
  • Openly discuss with your doctor the appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
  • Voice complaints or appeal decisions made by your health plan or about the care provided to you.

Members have the responsibility to:

  • Provide as much information as possible to your plan, practitioners and providers in order for them to provide the right care.
  • Follow plans and instructions for care that you and your doctor have agreed to.
  • Understand the condition of your health and participate in developing mutually agreed-upon treatment goals, as much as possible.
  • Know and confirm your benefits and eligibility before receiving services.

Learn more about member rights and responsibilities in the appeals for members section of our Administrative Manual.

 We encourage practitioners to freely communicate with patients

Practitioners are responsible for their relationship with each patient and are solely responsible for the medical care provided, including the discussion of treatment alternatives. Your Agreement does not limit your right to communicate freely with your patients, including the right to inform them services are appropriate or necessary, even if we determine the services are not covered by their plan.

 Use of practitioner and provider performance data

Measuring and reporting health care quality is important. Affiliated network practitioners and providers acknowledge and agree that the plan may use the performance data collected for quality improvement activities. Performance data collected includes, but is not limited to, member experience, HEDIS performance and appointment access data that is used to implement quality initiatives to improve care and service, as well as providing patients with information and tools to help them make informed choices to pursue the best available care.

 Referring patients to our Care Management program

Our Care Management program supports the unique needs of members with acute, chronic and major illness episodes or severe illness conditions. The mission of care management is to prioritize the needs of our members in their communities by providing personalized, equitable services that enhance their quality of wellbeing.

Care Management goals include:

  • Advocating for members and their support systems
  • Improving care through close collaboration with providers
  • Supporting members as they navigate the health care system
  • Educating members about their care options, benefits and coverage
  • Ensuring full compliance with national quality standards, including those established by NCQA
  • Supplementing information given by providers to help members make educated decisions regarding their health care
  • Improving members' clinical, functional, emotional and psychosocial status by supporting their health and wellness needs, as well as their independence

Providers can contact our Care Management Intake Team to refer members to care management. Members can also self-refer to our program. In addition, we proactively identify and outreach to those members most likely to benefit from additional support, education and collaboration with providers.

Once a member is identified, the designated case manager calls the member. We attempt at least three calls before sending a letter to the member. The member can respond to the letter if they want to engage with a case manager. Providers are sent a letter or contacted by phone when their patient is enrolled in care management.

You can also refer members to participate in the program by contacting our care management team or completing the care management referral request:

 Clinical Practice and Preventive Guidelines

Clinical Practice and Preventive Guidelines are systematically developed statements on medical practices that help physicians and other practitioners make decisions about appropriate health care for specific medical conditions.

The Plan adopts guidelines to assist health care professionals in recommended courses of intervention, but not as a substitute for an individual clinician's judgment. CPGs also help form the basis for designing appropriate disease management program interventions, coaching and wellness program content, and other health care programs at BridgeSpan Health.

 Policy prohibiting financial decisions for staff who make utilization management decisions about care and service

Utilization management decisions are based only on appropriateness of care and service and the existence of coverage. There are no rewards or incentives for practitioners or other individuals for issuing denials of coverage, service, or care. There are no financial incentives for utilization management decision-makers to encourage decisions that would result in underutilization.

 Access and network adequacy standards and policies

We are committed to providing our members the necessary information to:

  • Be able to use their health plan benefits
  • Have reasonable access to health services
  • Be assured the number of physicians, other health care professionals and facilities will be appropriate to satisfy their health care needs.

Learn more about our accessibility and availability standards.

 Obtaining utilization management criteria

You can obtain a copy of the clinical rationale, diagnosis and treatment codes and their meanings, as well as any other information used to make utilization management decisions, free of charge, by calling 1 (855) 238-9317. For pharmacy inquiries, please call 1 (844) 765-6827.

 How to contact our utilization management staff

Utilization management (UM) staffs are available from 7:00 a.m. to 5:00 p.m., Pacific Time, and from 8:00 a.m. to 6:00 p.m. Mountain Time. Staff can receive inbound communication regarding UM issues after normal business hours via voice mail and by fax. Communications received after normal business hours are returned on the next business day.

Utilization management staff are also responsible for pre-authorization requests. Utilization management staff can be reached at the following toll-free numbers.

 Pharmaceutical management
 Practitioner Rights

Providers have the right to review information submitted to support their credentialing application, including review of information submitted from outside sources, e.g., malpractice insurance and state licensing boards. Providers may also request information about the status of his/her application or reapplication. Application status requests are responded to and tracked in the providers credentialing file. Information that is allowed to be shared is the current status, outstanding requests and process timeframes. Peer protected and confidential information prohibited by law cannot be disclosed.

In the event that erroneous or conflicting information is discovered in a Credentialing application, the provider will be notified in writing of the right to dispute and/or correct the information (subject to any restrictions provided by a verification source, or otherwise prohibited by law). The Provider must submit a detailed explanation of all clarifications and corrections in writing, within fifteen (15) business days of the request, to the credentialing staff by fax at (888) 335-3002. The credentialing staff documents receipt of corrected credentialing information in the provider's credentialing file.

 Practitioner appeal process

Learn more about our appeal process for providers in our Administrative Manual.

 Medical record documentation

View the requirements for medical record keeping which is available on the Site Reviews Standard tab.