Member Rights and Responsibilities
Trillium Oregon Health Plan
Member Rights and Responsibilities Statement
This statement explains your rights and responsibilities as a Trillium Community Health Plan (Trillium) member.
As a member you have certain rights. You also have the responsibility to be a part of your health care. As your health care partner, we make sure your rights are guarded while we provide your health benefits. This includes providing you access to ournetwork providers and providing information you need to make the best decisions for your health and welfare. We also honor your right to privacy and to receive care withrespect and dignity.
If you are a child or are unable to make choices about your medical care, your legal guardian or agent has responsibility for ensuring your member rights on your behalf.
YOUR MEMBER RIGHTS:
- Be treated with dignity and respect;
- Be treated by participating providers the same as other people seeking health care benefits to which they are entitled and to be encouraged to work with the member’s care team, including providers and community resources appropriate to the member’s needs;
- Choose a Primary Care Provider (PCP) or service site and to change those choices as permitted by Trillium administrative policies;
- Refer oneself directly to behavioral health or family planning services without getting a referral from a PCP or other participating provider;
- Have a friend, family member, or advocate present during appointments and other times as needed within clinical guidelines;
- Be actively involved in the development of your treatment plan;
- Be given information about your condition and covered and non-covered services to allow you to make an informed decision about proposed treatments;
- Consent to treatment or refuse services and be told the consequences of that decision, except for court ordered services;
- Receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency;
- Have written materials explained in a manner that is understandable to you and be educated about the coordinated care approach being used in the community and how to navigate the coordinated health care system;
- Receive culturally and linguistically appropriate services and supports in locations close to where you live or seek services as possible and choice of providers within the Trillium network that are, if available, offered in non-traditional settings that are accessible to families, diverse communities, and underserved populations;
- Receive oversight, care coordination and transition and planning management from Trillium to ensure culturally and linguistically appropriate community-based care is provided in a way that serves you in as natural and integrated an environment as possible and that minimizes the use of institutional care;
- Receive necessary and reasonable services to diagnose the presenting condition;
- Receive integrated person-centered care and services designed to provide choice, independence and dignity and that meet generally accepted standards of practice and are medically appropriate;
- Receive assistance in navigating the health care delivery system and in accessing community and social support services and statewide resources including but not limited to the use of certified or qualified health care interpreters advocates, community health workers, peer wellness specialists, and personal health navigators who are part of the your care team to provide cultural and linguistic assistance appropriate to the your need to access appropriate services and participate in processes affecting the your care and services;
- Obtain covered preventive services;
- Have access to urgent and emergency services 24 hours a day, seven days a week without prior authorization;
- Receive a referral to specialty providers for medically appropriate covered coordinated care services as indicated in Trillium referral policies;
- Have a clinical record maintained that documents conditions, services received, and referrals made;
- Have access to your own clinical record, unless restricted by statute;
- Transfer of a copy of your clinical record to another provider;
- Be able to make a complaint or appeal with Trillium and receive a response;
- Request a contested case hearing;
- Receive certified or qualified health care interpreter services;
- Receive a notice of an appointment cancellation in a timely manner;
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, as specified in other federal regulations on the use of restraints and seclusion.
- Members have the right to request a copy of clinical practice guidelines. Clinical practice guidelines are statements that include health recommendations. These are to help improve the quality of care received by the patient. A paper copy can be mailed if requested. Members can also go to the Trillium website. Trilliumohp.com, under Member Resources. Member Rights and Responsibilities.
- Choose or help with assignment to a PCP or service site;
- Treat the CCO, provider, and clinic staff members with respect;
- Be on time for appointments made with providers and to call in advance to cancel if unable to keep the appointment or if expected to be late;
- Seek periodic health exams and preventive services from the PCP or clinic;
- Use the PCP or clinic for diagnostic and other care except in an emergency;
- Obtain a referral to a specialist from your PCP or clinic before seeking care from a specialist unless self-referral to the specialist is allowed;
- Use urgent and emergency services appropriately and notify your PCP or clinic within 72 hours of using emergency services.
- Give accurate information to be included in your clinical record;
- Help your provider or clinic obtain your clinical records from other providers that may include signing an authorization for release of information;
- Ask questions about conditions, treatments, and other issues related to your care that you do not understand;
- Use information provided by Trillium providers or care teams to make informed decisions about treatment before it is given;
- Help in the creation of a treatment plan with your provider;
- Follow prescribed agreed upon treatment plans and actively engage in your health care;
- Tell the provider that your health care is covered under Trillium before services are received and, if requested, show the provider your Trillium Member ID card;
- Tell Oregon Health Plan of a change of address or phone number;
- Tell Oregon Health Plan if you become pregnant and notify Oregon Health Plan of the birth of the your child;
- Tell Oregon Health Plan if any family members move in or out of the household;
- Tell Oregon Health Plan if there is any other insurance available;
- Assist Trillium in pursuing any third-party resources available and reimburse Trillium the amount of benefits it paid for an injury from any recovery received from that injury; and
- Bring issues or complaints or grievances to the attention of the Trillium.
For additional information or to request this information in another language or format, please call Member Services Toll Free: 1 (877) 600-5472 or TDD/TTY: 711
Trillium Member Services is available to answer your call directly 8 a.m. to 5 p.m., Monday through Friday (except on holidays).
Trillium Utilization Management (UM) staff is available to answer calls from 8 a.m. to 5 p.m., Monday through Friday (except holidays). UM staff makes decisions based on insurance coverage and medical need. UM staff can be reached by calling Member Services.
Our automated system is available anytime for self-service options, including after hours, weekends, and holidays. Voice messages are reviewed and responded to within one business day. Member Services also has free language interpreter service available for non-English speakers.
MCA_EK03V4 Effective 1/11/2019