Valley Health Plan Member Rights & Responsibilities

For Members > Rights & Responsibilities

VHP Member Rights & Responsibilities in Healthcare

Valley Health Plan has made a commitment to you by teaming up with our healthcare providers and support staff to provide you with care for your health services. As part of the team, you work with the other players to get the care you need. Each team member has rights and responsibilities to make sure the best care is available. Take time to learn the roles of everyone on your health care team.

You have the right to:

Receive information about Valley Health Plan and your health plan benefits, your rights and responsibilities, information on all of the services offered to you and how and when you can use them. You also have the right to receive the names of the participating doctors, hospitals, pharmacies, and other health care providers and health care places you have available to you;

Be treated with respect and with dignity, to have your personal health information be kept secure and confidential, and you have a right to your privacy;

Be involved with doctors and other health care professionals in the decision-making process regarding your health care;

Talk over your health care needs with the health care professionals caring for you, and to have a clear and open talk with them about appropriate or medically necessary care available for your condition, without concern for the cost or whether it is covered by your health plan benefits;

Make a written or spoken suggestion, expression of dissatisfaction, or complaint about the care or service you received from a participating health care professional or provider, or about the service you received from your health plan, and you may appeal any decision made relating to you or your health plan benefits and/or health plan services.

Write to Valley Health Plan with ideas or questions about this statement on member rights and responsibilities. Your letter can be sent to the Quality Improvement Work Group at Valley Health Plan, 2270 EastRidge Center,

PO Box 3128, Eau Claire, WI 54701.

Be given the first name of any staff member involved in your care and you may speak with their supervisor if desired.

Refuse to take part in any Valley Health Plan sponsored activity or program, or you may leave the program at any time. If you decide to take part in an activity or program, you will be told of any changes.

To help participating health care professionals and providers in meeting these responsibilities to you, it is your duty to:

Give patient identification and medical information, to the best of your ability, that your health care professionals and providers need in order to care for you;

Give patient identification and medical information, to the best of your ability, that your health plan needs in order to provide service to you;

To the best of your ability, work with your doctor to be aware of and understand your health issues so you can choose your health care treatment and goals.

Follow the prescribed medical plan and health care instructions that you have agreed upon with your doctor or other health care professional and tell him/her if you decide to take part in any Valley Health Plan sponsored activity or program.

Provide member consent to Valley Health Plan if required by any applicable state or federal law or regulation, when you have decided to sign up for a Valley Health Plan sponsored activity or program.

About Confidentiality
Your signed enrollment form includes a general release of information granting VHP the right to obtain personal medical information (PMI). This release is used only for purposes of underwriting (if necessary), benefit administration, referral requests, subrogation, appeal process, reporting (administrative function) and coordination of benefits. VHP does not keep medical records for our members. If you need to obtain your medical records, please contact the provider of services. VHP and our providers adhere to a policy that will protect and maintain a high level of confidentiality. Information necessary for reporting, including employer requests, does not include any member identifiable data. In all other instances, VHP will obtain a signed request authorization form from you to request PMI.

Grievance and External Review Process
A grievance is defined as a written expression of dissatisfaction with the administration, claims practices, or provision of services by the insurer. Grievances are filed with the Grievance Department as directed in the member handbook. Members, or their authorized representatives, have the option to appear before the Grievance Committee and present information regarding their grievance. In most cases, a determination of the grievance is communicated to the member within 30 calendar days of receipt. If we need additional time, we will notify you of the reason why and when you can expect a decision. If we uphold a claim denial in the grievance process, you may be eligible to request external review of your claim by an independent review organization (IRO). However, you do not need to complete our internal grievance process if you need immediate medical treatment and the time period for completing the grievance process would cause a delay that could jeopardize your life or health. You may also bypass our internal grievance process if we agree that it is in everyone's best interest to proceed directly to external review. An IRO is not connected to Valley Health Plan and is not bound by our previous decision. To qualify for external review, your claim must involve the following:

A determination that the treatment is not medically necessary. This includes a denial of a referral to an out-of-network provider when you believe the clinical expertise of the provider may be medically necessary for treatment of your medical condition and that expertise is not available in our provider network.

A determination that the treatment is experimental / investigational.

In either case, the treatment must cost at least $256 in order to qualify for external review

If you wish to pursue external review, you or your authorized representative must notify the applicable Appeal Department in writing at the following address:

Valley Health Plan
Attn: Grievance Department
P.O. Box 641
Milwaukee, WI 53201-0641

The request must include the following:

Your name, address and phone number,

The name of the IRO you have selected and a $25 check made payable to that IRO,

An explanation of why you think the treatment should be covered,

Any additional information / documentation that supports your position, and

If someone else is filing on your behalf, a statement signed by you, the member, authorizing that person to be your representative.

We must receive the request within 4 months of the date that we denied your grievance. Once we have received your request we will notify the IRO and the Commissioner of Insurance. We will also send the IRO copies of the information we relied on in your grievance and any additional information you supplied. The IRO will review this material and request any additional information they need. Once the IRO has received all the necessary information, it will have 30 days to render a decision. That decision will be provided to you in writing.

If your case involves a situation where the standard external review process would jeopardize your life, health, or ability to regain maximum function, you may send your external review request directly to the IRO and copy us. The IRO will have 72 hours to make a decision once they have received all necessary information.

The decision of the independent review organization is binding. If the IRO overturns our decision, We will refund the $25 you paid when requesting the review. Please refer to your benefit booklets or call Customer Relations if you have additional questions about this process.

Please review the OCI's "Fact Sheet on the Independent Review Process in Wisconsin" and the list of participating IROs, both of which are available at OCI's website oci.wi.gov, by clicking on the "Consumer" link, for additional information.


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